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A  MANUAL  OP  TREATMENT 

THE  VENEREAL  DISEASES 


CIVILIAN  EDITION 


RQgQl 


Aini 


Columbia  (Bntoerattp 

College  of  ^fjpstctang  anb  gmrgeona 
ILibxavy 


THE  VENEREAL  DISEASES 

An   Outline   of    Their    Management,   Prepared  Under  th( 

Direction  of  the  Surgeon  General  of  the 

Army  for  the  Use  of  Medical 

Officers 


REVISED  FOR  USE  OF  CIVILIAN  PHYSICIANS 


THIRD  EDITION 


PRINTED  FOR  THE 

UNITED  STATES  PUBLIC   HEALTH  SERVICE 

RUPERT  BLUE,   Surgeon  General. 


Chicago 

American   Medical  Association,   535   North   Dearborn  Street 

1919 


COMPLIMENTARY  COPY  PRESENTED  BY  THE 

UNITED   STATES   PUBLIC  HEALTH  SERVICE 

Division  of  Venereal  Diseases 

TU3 


V] 


Previous    editions    of   this   manual    have    been    printed    to    the   amount 
of    38,000    copies.     This   edition,    70,000    copies. ' 

PRICE  25  CENTS 

Copyright.    1919 

BY 

American    Medical   Association 


COMMITTEE     ON     VENEREAL     DISEASES 


William  Allen  Pusey  Francis  R.  Hagner 

Grover  W.  Wende  John  H.  Cunningham 

William  F.   Snow,  Lieutenant-Colonel.   Medical   Corps 

Warren  Walker,   Major,   Medical   Corps,   Secretary 


I  F.  Russel,  Colonel,  Medical  Corps,  in  Charge  of  Infectious 
Diseases,  Surgeon-General's  Office,  U.  S.  Army 

C   C.  Pierce,  Assistant  Surgeon-General,   in   Charge  of 
Venereal   Diseases,   U.   S.   Public   Health    Service 


TABLE     OF     CONTENTS 


T3        1-        •  XT  PAGE 

Preliminary  A  ote 9 

Introduction    10 

THE    VENEREAL    DISEASES 

Reports  of  venereal  infections ,    12 

Instruction  of  patients 12 

Laboratory  examinations _    \o 

Prevention  of  infection 13 

Prophylaxis   of  venereal   diseases 14 

Administration  of  early  or  prophylactic  treatment  to 

male  patients %   15 

Administration  of  early  or  prophylactic  treatment  to 
female  patients #    15 

THE    DIAGNOSIS    AND     TREATMENT 
OF     SYPHILIS 

Case  records 19 

Importance  of  early  diagnosis 19 

Examination  for  spirochaetae  pallidae  and  diagnosis 21 

Treatment  of  the   chancre : 25 

Systemic  treatment 26 

Arsphenamine   treatment 26 

Preparation  and  care  of  patient 28 

Reactions  from  arsphenamine !  28 

Early    reactions 29 

Late   reactions 32 

Neurorecurrences    $7 

Technic  of  arsphenamine  administration 38 

Technic  of  neoarsphenamine  administration 42 

Mercury   treatment 43 

Inunctions    '44 

Injections  '  '  45 

Technic   of  injections 45 


Care  of  patient  while  taking  mercury 48 

Salivation   ". 49 

Estimating  the  course  of  cases 50 

Late  syphilis 51 

Summary   55 

CHAXCROID 

Diagnosis    62 

General  treatment *. 62 

Local  treatment 63 

Bubo  68 

BALANITIS     GANGRENOSA 

Erosive  or  gangrenous  balanitis 72 

Etiology   73 

Diagnosis    74 

Treatment    75 

THE  TREATMENT    OF  GONORRHEA 

General    considerations 76 

Two-glass   test 77 

Microscopic   examination  of  pus 78 

The  gonococcus 79 

Prognosis    80 

Acute    gonorrhea 82 

Severe    acute   urethritis 84 

Local  treatment 85 

Subacute  anterior   urethritis 86 

Irrigation    \ . . .  87 

Acute  posterior  urethritis 90 

Treatment    91 

Complications  of  acute  gonorrhea 93 

Folliculitis    93 

Chordee  93 

Epididymitis    94 


Acute   prostatitis 95 

Prostatic  abscess 96 

Acute   seminal   vesiculitis 97 

Gonorrheal    -  c hthalmia 97 

Chronic   gonorrhea 98 

Chronic    anterior    urethritis 99 

Treatment 100 

Glandular  urethritis '. 102 

Chronic  posterior  urethritis 105 

Diagnosis    •. 105 

Treatment 106 

Cure' Ill 

Test  of  cure  of  gonorrhea 112 

Gonorrheal  rheumatism  and  metastatic  gonorrhea 112 

Summary  of  management  of  gonorrhea 115 

TREATMENT    OF    GONORRHEA    IN    WOMEN 

General  consideration  and  pathology 128 

Acute  cervicitis  and  endocervicitis 131 

Chronic   endocervicitis    and    cervicitis 132 

Vaginitis    133 

Vulvitis    134 

Bartholinitis    134 

Urethritis    135 

Cystitis   136 

Metritis  and  endometritis 136 

Salpingitis  and  ovaritis 138 

APPENDIX 

Program  of  attack  on  venereal  diseases 143 

Instruction  for  those  having  syphilis 153 

Instructions  for  those  having  gonorrhea 157 


PRELIMINARY     NOTE 


This  manual  was  originally  prepared  for  the  use 
of  the  Medical  Department  of  the  Army.  It  has  been 
adopted  by  the  Surgeon-General  of  the  Public  Health 
Service,  for  distribution  to  civilian  physicians.  Very 
few  modifications  have  been  found  necessary.  A  chap- 
ter on  gonorrhea  in  women  has  been  added,  for  which 
thanks  are  due  to  Dr.  N.  Sproat  Heaney,  Assistant 
Professor  of  Gynecology,  Rush  Medical  College,  Chi- 
cago. 

The  purpose  of  this  manual  is  to  give  definite 
instructions  in  approved  methods  of  treatment  of  the 
venereal  diseases,  to  the  end  that  the  reader  may  easily 
inform  himself  in  them  without  being  confused  by  a 
multiplicity  of  details.  It  is  believed  that  the  articles 
are  sufficiently  full  to  cover  the  essential  facts. 
Descriptions  of  complicated  procedures,  requiring 
special  trained  skill  for  their  carrying  out  have  inten- 
tionally been  omitted ;  cases  requiring  treatment  of 
this  sort  should  be  referred  to  a  trained  urologist. 

It  is  the  impression  of  the  committee  that  what  the 
profession  of  the  country  most  lacks  in  the  treatment 
of  venereal  diseases  is,  not  general  information  as  to 
the  treatment  of  these  diseases,  but  precise  knowledge 
of  the  most  approved  methods  and  plans  by  which  this 
treatment  is  carried  out.  It  is  the  particular  aim  of 
the  manual  to  supply  this  sort  of  knowledge. 


INTRODUCTION 


The  war  has  made  it  possible  and  necessary  for 
venereal  diseases  to  receive  the  attention  that  they 
deserve,  from  health  authorities,  from  physicians  and 
from  the  general  public.  The  government  is  devoting 
an  immense  amount  of  money  and  labor  to  the  control 
of  these  diseases.  The  "Program  of  Attack  on  the 
Venereal  Diseases"  (see  Appendix)  is  being  followed 
with  the  greatest  determination  by  the  War  Depart- 
ment. The  result  is  that  the  incidence  of  new  cases  of 
venereal  diseases  in  our  army  is  much  less  than  half 
of  what  it  ever  was  before  this  war. 

During  the  year  ending  Sept.  15,  1918,  the  records 
of  the  office  of  the  Surgeon-General  of  the  Army  show 
that  a  total  of  169,325  cases  of  venereal  diseases  were 
treated  in  our  army.  Of  this  number,  approximately 
one  sixth  wTere  acquired  after  the  men  entered  the 
army  camps ;  the  remaining  five  sixths  were  brought 
in  from  civilian  life.  It  is  not  necessary  to  elaborate 
on  the  fact  of  how  common  has  been  this  burden  on 
the  Army.  The  Navy,  too,  has  carried  a  similar  bur- 
den of  venereal  disease. 

In  addition,  the  venereal  diseases  have  hindered  war 
preparations  by  reducing  the  output  of  munition  plants 


INTRODUCTION  11 

and  other  factories,  coal  mines,  shipyards,  etc.  These 
diseases  among  the  civilian  population  have,  therefore, 
been  of  the  greatest  importance  in  relation  to  the  win- 
ning of  the  great  war,  and  this  military  importance  has 
demanded  that  the  utmost  efforts  be  made  immediately 
to  reduce  their  prevalence.  In  addition,  the  general 
public  has  been  educated  to  the  stern  necessity  of  com- 
bating venereal  diseases  in  times  of  peace  as  well  as  of 
war;  for  these  statistics  of  the  draft  boards  have  given 
indisputable  evidence  of  the  alarming  prevalence  of 
these  diseases  throughout  the  civilian  population. 

The  prevention  of  these  diseases,  in  the  ways  indi- 
cated in  the  "Program  of  Attack"  (pages  143  to  152), 
is  a  task  resting  largely  on  the  civilian  physicians,  as 
well  as  on  those  forces  that  make  for  good  govern- 
ment, high  moral  standards,  and  the  proper  training  of 
our  youth.  The  physician  bears  the  responsibility  for 
the  strictly  medical  efforts  of  prevention,  the  responsi- 
bility for  making  an  accurate  diagnosis  in  each  case  as 
it  presents  itself,  and  for  giving  the  patient  thorough 
treatment  and  instruction ;  and  he  bears  the  further 
responsibility  for  reporting  each  case  to  the  health 
authorities,  and  for  otherwise  faithfully  observing  the 
laws  of  his  state  with  regard  to  the  prevention  of  the 
venereal  diseases. 


12  THE     VENEREAL     DISEASES 

REPORTS     OF     VENEREAL     INFECTIONS 

Cases  of  syphilis,  gonorrhea  and  chancroid  are  to  be 
reported  to  the  health  authorities  in  accordance  with 
state  or  local  laws  and  ordinances.  The  source  of  the 
patient's  infection,  namely,  the  individual  from  whom 
he  or  she  contracted  the  disease,  should  be  ascertained 
if  possible,  and  the  patient  instructed  to  advise  that 
person  to  seek  treatment.  Where  persons  are  wilfully 
and  negligently  spreading  the  disease  to  others,  report 
of  that  fact  should  be  made  to  the  proper  authorities. 

INSTRUCTION     OF     PATIENTS 

Each  patient  is  to  be  thoroughly  instructed  in  the 
nature  of  his  disease,  its  means  of  spread,  and  the 
necessity  of  continuing  treatment  until  cured.  Verbal 
instruction  by  the  physician  is  most  important.  Printed 
instructions  (see  Appendix,  pages  153  to  159)  will  also 
be  furnished  free  of  charge  by  the  state  or  municipal 
board  of  health  in  many  states.  When  not  otherwise 
obtainable,  they  will  be  jsent  on  request  by  the  Division 
of  Venereal  Diseases,  United  States  Public  Health 
Service,  Washington,  D.  C. 

LABORATORY     EXAMINATIONS 

The  diagnosis  of  syphilis  is  to  be  confirmed  by  the 
Wassermann  test,  and  that  of  gonorrhea  by  micro- 
scopic examinations,  whenever  possible.  These  exam- 
inations are  made  free  of  charge  by  many  state  or  city 


INTRODUCTION  13 

boards  of  health.  Where  this  is  not  the  case,  it  is 
strongly  recommended  that  the  physician  arrange  to 
have  these  examinations  made  for  him  by  a  thor- 
oughly qualified  laboratory. 

PREVENTION      OF     INFECTION 

It  is  the  duty  of  the  physician  to  urge  continence  in 
unmarried  individuals,  not  only  as  the  surest  means 
of  preventing  venereal  infections,  but  also  because  the 
best  interests  of  the  individual  and  of  the  race  demand 
a  clean  life.  It  should  be  pointed  out  to  such  persons 
that  clean  thinking,  the  selection  of  the  best  type  of 
associates,  active  employment,  and  outdoor  sports  and 
other  wholesome  recreations,  render  the  control  of  the 
sex  impulse  possible,  even  for  those  persons  who  previ- 
ously have  not  practiced  continence  (see  Appendix, 
"Program  of  Attack,"  pages  143  to  152).  Young  men 
especially  should  be  sympathetically  taught  and  encour- 
aged to  exercise  self-control  and  live  continent  lives. 

In  the  case  of  persons  who  have  failed  to  do  this, 
and  have  exposed  themselves  to  venereal  diseases, 
humanity  demands  that  every  effort  should  be  made 
to  prevent  these  serious  infections  from  developing. 
Such  persons  should  consult  their  physician  imme- 
diately, in  order  to  receive  the  early  (prophylactic J 
treatment  within  an  hour  after  exposure.  (See  Appen- 
dix, pages  147  to  149.) 


PROPHYLAXIS     OF     VENEREAL     DISEASES 


The  importance  of  social  and  educational  measures 
tending  to  reduce  the  prevalence  of  the  venereal  dis- 
eases is  to  be  strongly  emphasized.  Such  measures 
as  applied  successfully  in  the  Army  are  referred  to 
under  "Program  of  Attack  on  Venereal  Diseases/' 
(pages  146-147).  The  various  measures  there  men- 
tioned might  well  be  put  into  effect  in  every  city  and 
town,  with  certain  modifications  which  will  suggest 
themselves  to  make  them  apply  in  civilian  communities. 

In  addition,  methods  of  medical  prophylaxis  are  also 
of  the  highest  importance  in  cases  where  they  can  be 
scientifically  applied.  Every  extramarital  intercourse 
is  to  be  regarded  as  an  exposure  to  venereal  infection, 
and  this  infection  should  if  possible  be  prevented  from 
development.  The  so-called  prophylactic  treatment  is 
really  early  treatment,  applied  to  the  venereal  diseases 
in  their  earliest  stage,  before  the  infecting  organisms 
have  penetrated  into  the  tissues. 

Such  treatment  is  very  efficacious  in  preventing  the 
development  of  venereal  infection  if  given  within  the 
first  hour  after  exposure.  Its  value  rapidly  diminishes 
from  then  on,  and  when  eight  hours  have  elapsed  since 


PROPHYLAXIS     OF     VENEREAL     DISEASES      15 

the  exposure  its  value  is  greatly  reduced.  It  should, 
however,  be  given  up  to  at  least  twelve  hours  after 
exposure.  Cases  applying  at  a  later  time  than  this 
should  be  instructed  simply  to  bathe  thoroughly  with 
soap  and  water,  and  in  the  case  of  females  also  to  take 
a  douche.  All  persons  giving  a  history  of  exposure 
should  report  to  their  physician  for  examination  every 
second  day  for  ten  days,  and  after  that  weekly  for  two 
months,  in  order  that  any  infection  may  be  detected 
at  the  earliest  moment,  and  they  themselves  should  be 
instructed  to  watch  for  suspicious  symptoms.  Patients 
should  not  have  sexual  intercourse  during  the  time 
that  they  are  under  observation. 

ADMINISTRATION     OF     EARLY     OR     PROPHYLACTIC 
TREATMENT     TO      MALE     PATIENTS 

Have  the  patient  urinate. 

Wash  genitals  and  adjacent  parts  with  soap  and 
water,  followed  by  a  1-2000  mercuric  chlorid  solution. 
Dry  the  parts  thoroughly. 

Inject  a  2  per  cent,  protargol  solution,  or  a  10  per 
cent,  argyrol  solution,  or  an  equivalent  solution  freshly 
made,  into  the  urethra,  enough  to  distend  it  moder- 
ately, and  see  that  the  patient  holds  the  solution  for 
five  minutes  before  expelling  it. 


16  THE     VENEREAL     DISEASES 

Anoint  the  whole  of  the  penis  and  scrotum  with  33 
per  cent,  calomel  ointment,  rubbing  in  thoroughly, 
using  special  care  about  the  folds  of  the  frenum,  fore- 
skin, and  scrotum,  and  taking  at  least  ten  minutes  for 
the  operation.  Cover  genitals  with  oiled  silk  or  waxed 
paper,  and  allow  to  remain  for  several  hours  before 
washing  the  parts. 

The  formula  for  calomel  ointment  used  in  the  United 
States  Army,  which  has  proved  its  efficacy,  is  as  fol- 

l0WS:  Parts 

Hydragyri  chloridum  mite 30 

Adeps  benzoinatus 65 

Cera  alba,  U.  S.  P 5 

ADMINISTRATION     OF     EARLY     OR     PROPHYLACTIC 
TREATMENT     TO     FEMALE     PATIENTS 

In  cases  of  rape,  and  in  some  others,  there  may  be 
occasion  for  applying  early  treatment  to  females.  If 
such  occasion  should  arise,  the  following  procedure  is 

suggested : 

Have  patient  urinate. 

Place  patient  in  lithotomy  position.  Wash  the  geni- 
tals and  adjacent  parts  with  soap  and  water.  Give  a 
douche  of  two  quarts  of  sterile  water,  temperature  100 
F.,  followed  by  two  quarts  of  1-2000  mercuric  chlorid 


PROPHYLAXIS     OF     VENEREAL     DISEASES      17 

solution,  and  wash  external  parts  with  the  latter.  Dry 
vagina  and  vulva  by  sponging.  Swab  entire  vagina, 
through  a  speculum,  with  a  2  per  cent,  protargol  solu- 
tion, or  10  per  cent,  argyrol  solution,  freshly  made ; 
reach  every  fold  and  especially  the  posterior  vault  and 
external  os.  Swab  entire  vulva  in  the  same  way, 
reaching  every  recess  and  endeavoring  to  facilitate  the 
entrance  of  the  solution  into  the  openings  of  Skene's 
ducts  and  Bartholin's  glands.  Inject  enough  of 
the  same  solution  into  the  urethra  to  distend  it  mod- 
erately and  let  patient  hold  her  finger  (in  a  rubber 
glove)  against  the  meatus  to  retain  the  solution  for 
from  three  to  five  minutes. 

Douche  vagina  and  vulva  with  a  small  amount  of 
sterile  water,  and  sponge  dry.  Apply  calomel  ointment 
to  the  cervix,  vagina,  vulva  and  adjacent  parts,  rubbing 
thoroughly  into  the  recesses  and  folds  of  the  mucous 
membranes  and  skin,  and  taking  at  least  ten  minutes 
for  the  operation.  Do  not  use  more  than  4  gms. 
(1  dram)  of  calomel  ointment  in  vagina.  Cover 
external  parts  with  oiled  silk  or  waxed  paper  and 
instruct  patient  to  allow  ointment  to  remain  for  sev- 
eral hours  before  washing  the  parts. 


THE     DIAGNOSIS     AND     TREATMENT 
OF     SYPHILIS 


CASE     RECORDS 

Great  importance  is  attached  to  the  keeping  of  sys- 
tematic and  full  histories  of  venereal  cases.  The 
proper  treatment  of  syphilis  requires  that  an  accurate 
record  be  kept  in  each  case. 

All  infectious  cases  should  be  reported  promptly, 
according  to  law,  and  all  patients  should  be  given 
instructions  concerning  their  disease  (see  Appendix). 

IMPORTANCE     OF     EARLY     DIAGNOSIS 

From  the  standpoint  of  public  health,  early  diagnosis 
is  of  the  greatest  importance.  The  matter  of  prime 
importance  in  handling  syphilis  is  to  get  it  at  the  begin- 
ning of  the  infection.  The  earlier  it  is  treated  the 
better  are  the  prospects  of  cure,  and  the  quicker  the 
patient  can  be  made  noncontagious  and  fit  to  work. 
It  should  be  the  constant  effort  to  discover  syphilis  at 
the  earliest  possible  time,  if  possible  before  the  devel- 
opment of  a  positive  Wassermann  reaction. 

To  this  end,  every  sore,  whether  on  the  genitals  or 
elsewhere,  that  is  open  to  any  suspicion  of  being  a 
chancre,  should  be  repeatedly  examined  for  spiro- 
chetes.    No  determining  weight  should  be  given  to 


20  THE     VENEREAL     DISEASES 

the  so-called  specific  clinical  characteristics  of  any 
lesion  that  might  by  any  possibility  be  a  chancre. 
Experience  has  shown  that  the  typical  clinical  char- 
acteristics of  the  chancre,  aside  from  indolence — and 
this  may  be  masked  by  another  infection — are  often 
lacking*.  Any  excoriations,  papule,  nodule,  crack,  her- 
petic or  other  erosion,  no  matter  how  small,  may  be 
an  initial  lesion  of  syphilis;  and  such  lesions,  as  well 
as  ulcers  about  the  genitals — and  elsewhere,  if  there 
is  any  reason  to  suspect  them  or  if  they  are  indolent 
and  not  readily  to  be  accounted  for — should  be 
searched  for  spirochetes. 

Chancroids  in  particular  should  never  be  accepted 
as  uncomplicated  by  syphilitic  infection.  They  are 
likely  to  have  a  double  infection,  and  should  always 
be  zealously  examined  for  Spirochaetae  pallidae. 
Sometimes,  in  spite  of  the  most  careful  search,  the 
spirochetes  escape  detection  in  chancroids.  For  that 
reason,  one  can  never  be  sure  that  a  chancroid  does 
not  hide  a  chancre ;  patients  with  chancroid,  therefore, 
require  watching  for  the  possibility  of  syphilis,  and, 
when  the  spirochetes  cannot  be  found,  should  always 
have  weekly  Wassermann  tests  for  three  or  four  weeks 
until  the  question  of  syphilis  can  be  decided. 

Antiseptics,  especially  mercurials,  render  the  find- 
ing of  Spirochaetae  pallidae  difficult  or  impossible ; 


DIAGNOSIS   AND    TREATMENT    OF   SYPHILIS      21 

and,  because  of  this,  it  should  be  routine  practice  to 
apply  no  mercurial  dressings,  or  better,  no  antiseptic 
dressings,  to  suspicious  lesions  until  the  necessary 
examinations  to  exclude  Spirochaetae  pallidae  have 
been  made.  If  any  such  application  has  been  made  to 
a  suspected  lesion, the  lesion  should  be  thoroughly  irri- 
gated with  physiologic  sodium  chlorid  solution,  and 
a  wet  dressing  of  this  solution  applied  for  twelve 
hours  or  more  before  examining  for  spirochetes. 

In  order  to  aid  in  discovering  the  initial  lesion  at 
the  earliest  moment  persons  who  have  been  exposed 
should  be  examined  at  intervals  of  a  few  days  for  at 
least  three  weeks,  and  also  instructed  to  be  themselves 
on  the  watch  for  suspicious  lesions. 

EXAMINATION     FOR     SPIROCHAETAE     PALLIDAE 
AND  DIAGNOSIS 

To  obtain  the  Spirochaetae  pallidae  for  examina- 
tion, two  procedures  are  of  value.  In  obtaining  them 
directly  from  the  lesion,  the  surface  should  be  wiped 
with  gauze  wet  with  physiologic  sodium  chlorid  solu- 
tion, to  remove  saprophytic  organisms,  especially  the 
Spirochaeta  ref  ring  ens.  The  rubbing  should  leave  a 
clean  oozing  surface,  no  bleeding.  Light  curettement 
may  be  necessary  in  some  cases.  Moderate  squeezing 
of  the  lesion  will  then  cause  an  exudation  of  lymph 


22  THE     VENEREAL     DISEASES 

from  the  deeper  portions  of  the  tissues.  A  drop  of 
this  lymph  is  then  touched  to  a  cover-glass  and  placed 
on  a  slide,  or  the  fluid  may  be  collected  in  a  capillary 
pipet.  It  may  be  preserved  for  a  few  hours  by  seal- 
ing the  pipet,  or  the  specimen  on  the  slide  may  be 
ringed  with  paraffin  or  petrolatum  and  kept  on  ice 
for  variable  periods  up  to  twelve  hours  or  longer. 
Delay  impairs  the  validity  of  the  findings,  however, 
and  multiplies  uncertainties,  so  that  examination 
should  be  made  at  once. 

A  valuable  method,  which  relieves  the  observer  of 
much  of  the  responsibility  for  differential  diagnosis 
of  the  organism,  is  glandular  aspiration.  This  can 
be  done  on  prominent  nodes  in  the  satellite  adenopathy 
accompanying  the  primary  lesion.  It  can  also  be  per- 
formed on  the  indurated  base  of  a  suspected  chancre. 
A  sterile  glass  syringe,  of  1  c.c.  capacity,  fitted  with 
an  ordinary  stout  hypodermic  syringe  needle,  an  inch 
or  so  in  length,  is  sufficient.  The  skin  over  the  gland 
is  painted  with  iodin,  and  the  gland  palpated  and  fixed 
between  the  thumb  and  forefinger  of  the  left  hand. 
The  needle  is  plunged  through  the  skin  into  the  gland, 
the  penetration  of  the  capsule  being  indicated  by  the 
moving  of  the  gland  under  the  finger  when  the  posi- 
tion of  the  syringe  is  changed.    The  gland  is  then  held 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       23 

firmly  while  the  needle  is  manipulated  enough  to 
macerate  the  tissue  immediately  around  the  point. 
Aspiration  will  draw  a  drop  or  two  of  tissue  juice  into 
the  needle  and  barrel.  The  fluid  thus  obtained  is  often 
rich  in  Spirochaetae  pallidae.  The  method  is  not 
especially  painful,  and  .is  easily  borne  by  the  average 
patient. 

The  Spirochaeta  pallida,  as  obtained  for  study  by 
these  methods,  has  a  morphology  usually  easily  recog- 
nized by  the  experienced  observer.  It  L  a  regular 
spiral  organism,  of  from  6  to  15  microns  in  length, 
with  from  3  to  26  turns.  The  average  length  is  about 
twice  that  of  a  red  blood  cell,  and  the  usual  number 
of  turns  is  from  10  to  20.  It  is  rather  slow  moving, 
which  is  a  distinctive  characteristic.  A  movement  in 
the  direction  of  the  long  axis  and  a  rotating  movement 
are  most  commonly  observed.  The  organism  retains 
its  clear-cut,  regular  spiral  turns  exceptionally  well, 
even  at  rest — another  distinctive  characteristic.  Long 
forms  bent  in  the  middle  are  occasionally  seen. 

From  Spirochaeta  refringens,  if  this  is  not  elimi- 
nated by  proper  cleansing,  the  Spirochaeta  pallida  is 
distinguished  by  the  fact  that  Spirochaeta  refringens  is 
obviously  coarser,  and  the  turns  are  fewer  and  less  reg- 
ular.    Spirochaeta  refringens  does  not  keep  its  cork- 


24  THE     VENEREAL     DISEASES 

screw  shape  so  well  as  Spirochaeta  pallida  when  at  rest, 
and  when  in  motion  moves  much  more  rapidly  than 
the  Spirochaeta  pallida.  Spirochaeta  dentium,  seen  in 
mouth  preparations,  is  much  more  minute  than  the 
Spirochaeta  pallida.  The  coils  are  more  acute  and 
more  lightly  rolled.  Fibrin  spirals  have  been  mistaken 
for  syphilitic  spirochetes  by  inexperienced  observers. 
In  general  it  may  be  said  that  while  the  recognition  of 
the  organism  of  syphilis  is  not  an  affair  for  the  tyro, 
a  moderate  amount'  of  experience  on  the  part  of  the 
examiner,  coupled  with  the  presence  of  numerous 
organisms  of  the  above  described  type  in  a  given  prep- 
aration made  under  favorable  conditions,  is  sufficient 
for  a  diagnosis  of  syphilis  and  the  institution  of  appro- 
priate treatment.  Failure  to  find  them,  however,  is 
no  evidence  that  the  lesion  is  not  syphilis. 

In  all  suspected  cases,  Wassermann  tests  should  be 
made.  It  should  be  made  a  general  rule  that  the  first 
finding  of  a  positive  Wassermann  reaction  should 
immediately  be  confirmed  by  a  second ;  but  it  is  not 
necessary  to  delay  beginning  treatment  until  the  sec- 
ond report  is  received.  For  the  first  ten  days  after 
the  appearance  of  the  chancre,  the  Wassermann  reac- 
tion is  usually  negative.  It  is  at  this  critical  period 
that  the  establishment  of  the  diagnosis  of  syphilis  by 
demonstration  of  the  specific  spirochetes   is   of   such 


DIAGNOSIS    AND    TREATMENT    OF    SYPHILIS      25 

importance,  because  it  enables  us  to  begin  treatment 
while  the  infection  is  still  relatively  localized  and  can 
usually  be  aborted  by  thorough  treatment.  In  sus- 
pected chancres  in  which  spirochetes  cannot  be  found. 
YYassermann  tests  should  be  made  at  intervals  of  a 
week,  for  a  month,  before  it  is  decided  finally  that 
the  case  is  not  syphilis.  In  cases  in  which  the  spi- 
rochetes are  found,  a  Wassermann  test  should  be  made 
at  the  outset,  and  if  it  is  not  positive,  should  be 
repeated  at  weekly  intervals  for  the  first  few  weeks  to 
see  if,  in  spite  of  treatment,  it  becomes  positive.  Fur- 
ther Wassermann  tests  should  be  made  at  about 
monthly  intervals. 

In  no  case  should  specific  treatment  be  started  until 
a.  positive  diagnosis  of  syphilis  has  been  made. 

TREATMENT     OF     THE     CHANCRE 

Excision  of  the  chancre  is  a  procedure  which 
theoretically  sho'uld  be  useful,  on  the 'ground  that  it 
removes  the  important  focus  of  infection.  And  when 
the  location  of  the  chancre  is  such  that  its  excision 
will  not  cause  deformity,  surgical  excision  may  be 
lone;  but  excision  of  the  chancre  does  not  abort 
syphilis.  The  excised  chancre  should  be  preserved 
md  sent  for  laboratory  examination.  Until  the  search 
hor  spirochetes  is  ended,  the  chancre  should  be  treated 


26  THE     VENEREAL     DISEASES 

only  by  cleansing  with  saline  solution  and  covering 
with  a  compress  wet  with  the  same  solution.  As  soon 
as  spirochetes  are  demonstrated,  if  the  chancre  is  not 
excised,  it  should  receive  an  inunction  of  33  per  cent. 
calomel  ointment  twice  daily  for  a  week;  it  should 
be  kept  clean  and  protected  by  a  calomel  ointment  or 
some  bland  protecting  dressing. 

SYSTEMIC     TREATMENT 

In  the  presence  of  early  syphilis  treatment  should 
be  immediately  started  and  vigorously  pushed.  It 
should  be  with  both  arsphenamine  and  mercury. 
Before  beginning  there  should  be  a  preliminary  survey 
of  the  patient's  physical  condition.  Patients  with 
acute  febrile  diseases  or  with  diseases  of  the  liver,  kid- 
ney or  vascular  system — when  they  are  nonsyphilitic 
in  origin — should  be  given  arsphenamine  with  caution. 

ARSPHENAMINE  x 

There  is  agreement  among  syphilographers  that  the 
most  effective  time  for  producing  radical  results  with 
arsphenamine  is  in  the  first  few  weeks  of  syphilis — 


1.  Arsphenamine  is  the  official  name  now  applied  to  the  drug  for- 
merly called  salvarsan.  The  various  special  names,  such  as  arseno- 
benzol,  diarsenol  and  salvarsan,  are  proprietary  names  and  should  not 
be  used  unless  to  designate  the  particular  brand.  In  records  the  name 
arsphenamine  should  be  used,  and  the  special  name  or  the  manufac- 
turer's name  also   given. 


DIAGNOSIS   AND    TREATMENT    OF   SYPHILIS      27 

best  before  the  Wassermann  test  becomes  positive — 
and  that  arsphenamine  should  be  pushed  at  this  time. 

The  normal  dose  should  be  on  the  basis  of  1  deci- 
gram of  arsphenamine  for  each  30  pounds  of  body 
weight,  i.  e.,  from  4  to  6  decigrams  for  patients  of 
ordinary  weight.  The  first  dose  should  be  one-half 
the  normal  dose.  Administer  at  intervals  of  from 
five  to  seven  days.     Six  doses  constitute  a  course. 

It  is  possible  that  in  cases  seen  before  the  Wasser- 
mann test  has  become  positive,  one  such  course  of 
arsphenamine  combined  with  mercury  may  cure.  But 
this  is  not  safe  to  assume,  and,  in  the  light  of  our  past 
knowledge  of  syphilis,  it  is  advised  even  in  these  cases 
to  repeat  the  course  of  arsphenamine  and  mercury 
treatment  at  least  once  after  a  rest  period  of  from  six 
to  eight  weeks.  Such  patients  should  be  subsequently 
watched  for  a  year  with  monthly  Wassermann  tests 
and  treated,  should  any  evidence  of  syphilis  be  dis- 
covered. 

In  all  cases  seen  after  the  Wassermann  test  has 
become  positive  the  first  course  of  treatment  should 
be  followed  by  a  second  after  four  to  six  weeks'  rest. 
And  it  is  safest  to  give  at  least  a  third  similar  course 
after  an  interval  of  two  months  even  in  the  most 
promising  of  cases. 


28  THE     VENEREAL     DISEASES 

In  all  those  cases  in  which  a  positive  Wassermann 
test  or  any  other  evidence  of  syphilis  remains,  further 
courses  of  arsphenamine  and  mercury  should  be  given 
at  intervals  similar  to  the  foregoing,  the  persistence  in 
treatment  to  be  determined  by  the  findings  in  the  indi- 
vidual case. 

In  place  of  arsphenamine,  neoarsphenamine  can  be 
used  in  50  per  cent,  larger  doses.  It  may  be  somewhat 
less  effective,  but  the  difference  is  not  sufficient  to 
allow  of  dogmatic  statements  on  this  point. 

It  may  be  repeated  that  the  use  of  arsphenamine  is 
to  be  combined  with  that  of  mercury  in  the  attempt  at 
cure  of  syphilis;  and  that  reliance  is  not  to  be  placed 
on  arsphenamine  alone. 

PREPARATION     AND     CARE     OF     PATIENT 

The  urine  should  be  examined  before  each  injection 
of  arsphenamine.  Arsphenamine  should  be  given  with 
the  patient's  stomach  empty,  or  nearly  so.  The  treat- 
ments are  best  given  at  noon  or  in  the  early  afternoon, 
the  patient  omitting  lunch.  He  should  remain  quiet  for 
the  rest  of  the  day — best  in  bed — and  should  take 
no  food  until  the  next  morning. 

REACTIONS     FROM     ARSPHENAMINE 

As  a  rule  the  administration  of  arsphenamine  is 
followed    by   no    symptoms    whatever.      Occasionally, 


DIAGNOSIS   AND    TREATMENT    OF    SYPHILIS      29 

however,  reactions  occur  from  it ;  these  vary  in  severity 
from  slight,  evanescent  distress  to  symptoms  of  the 
gravest  poisoning. 

To  some  extent,  perhaps,  these  reactions  are  due  to 
individual  hypersensitiveness  to  the  drug.  There  is 
good  reason  to  believe,  however,  that  the  severe  reac- 
tions are  chiefly  produced  by  impurities  in  the  drug, 
due  to  faults  in  manufacture,  or  sometimes  to  oxida- 
tion produced  by  carelessness  in  technic  of  adminis- 
tration. 

The  reactions  may  be  divided  for  consideration  into 
early  and  late ;  the  early  reactions  occurring  from  the 
very  time  of  injection  to  six  or  eight  hours  afterward, 
and  the  late  occurring  from  one  to  four  or  five  days, 
and,  occasionally,  even  longer  afterward. 

The  early  reactions  have  the  symptoms  of  acute 
poisonings ;  the  late,  symptoms  of  organic  disturbances 
that  have  resulted  from  the  slower  action  of  a  poison. 

EARLY     REACTION 

Nausea :  The  commonest  reaction  after  arsphena- 
mine  is  a  feeling  of  malaise  with  some  nausea  from 
five  to  seven  hours  afterward.  Xot  infrequently  this 
amounts  to  a  chill,  followed  by  slight  fever  and  more 
or  less  severe  vomiting.  These  symptoms  disappear 
in  a  few  hours. 


30  THE     VENEREAL     DISEASES 

They  do  not  constitute  a  contraindication  to  the 
further  use  of  the  drug,  but  they  should  suggest  that 
more  care  than  usual  be  exercised  to  see  that,  before 
administration,  the  bowels  have  been  cleaned  out  and 
the  stomach  is  empty  and  that,  afterward,  the  patient 
rests  without  food  until  the  next  morning. 

Febrile  Reaction :  Rarely  these  reactions  are  more 
severe.  The  temperature  may  go  to  from  38  to  40  C. 
(101  to  104  F.)  with  headache  and  general  pains,  espe- 
cially of  the  legs  and  back,  diarrhea  as  well  as  nausea 
and  vomiting,  and  an  eruption  of  urticaria  or  toxic 
erythema.  The  treatment  is  rest  in  bed  and  a  liquid 
diet  until  symptoms  have  subsided.  The  pain  may  be 
controlled  by  a  few  doses  of  salicylates.  No  more 
arsphenamine  should  be  given  in  these  cases  until  sev- 
eral days  after  all  symptoms  have  disappeared,  and 
any  further  administration  of  the  drug  should  be  in 
relatively  small  doses  and  at  intervals  of  not  less  than 
a  week. 

Temporary  Albuminuria:  It  is  not  uncommon  to 
mid  a  trace  of  albumin  and  a  few  casts  in  the  wiext 
morning's  urine  after  an  injection  of  arsphenamine. 
This  is  not  a  contraindication  to  the  further  use  of 
the  drug  unless  the  albumin  is  present  in  considerable 
quantity  and  there  are  more  than  half  a  dozen  casts 
to  the  slide. 


DIAGNOSIS   AND    TREATMENT    OF   SYPHILIS       31 

Immediate  Acute  Reaction :  The  early  reaction  which 
in  rare  cases  accompanies  or  immediately  follows  the 
administration  of  arsphenamine  is  that  of  an  acute 
poisoning,  characterized  by  intense  congestion  from 
vasomotor  disturbances  ;  this  is  the  so-called  anaphylac- 
toid reaction  of  arsphenamine.  It  is  probably  due  to 
impurities  in  the  drug.  In  these  cases  the  patient 
suddenly — perhaps  before  the  injection  is  finished — 
manifests  symptoms  of  distress.  He  may  first  notice  a 
taste  of  garlic  or  ether,  or  of  a  metallic  substance. 
An  erythema  appears  on  the  neck  and  spreads  thence 
over  the  face,  and  the  jugular  pulse  is  exag- 
gerated and  rapid.  He  complains  of  faintness ;  the 
pulse  becomes  weak  and  the  respiration  labored. 
The  face  is  puffed  and  congested ;  the  pupils  dilate ; 
there  is  a  feeling  of  constriction  in  the  throat ;  and 
there  may  be  edema  of  the  glottis,  which  fortunately  is 
very*  rarely  fatal.  There  is  tightness  in  the  chest,  and 
especially  precordial  distress.  The  pulse  may  become 
imperceptible,  the  patient  cyanotic,  and  syncope  may 
occur.  Altogether  the  picture  is  extremely  alarming 
in  the  severe  cases,  but  fortunately  the  symptoms  as  a 
rule  quickly  improve,  and  recovery  nearly  always  takes 
place. 

These  cases  promptly  respond  to*  the  injection  of 
from  1  to  2  c.c.  of  1 :  1,000  solution  epinephrin  (adre- 


01 


THE     VENEREAL     DISEASES 


nalin),  which  may  be  repeated  at  intervals  of  twenty 
or  thirty  minutes,  if  required,  until  the  symptoms  sub- 
side. In  preparation  for  this  emergency  a  sterile 
hypodermic  syringe  with  2  c.c.  of  epinephrin  solution 
in  it  should  always  be  at  hand  when  arsphenamine  is 
given. 

The  occurrence  of  this  reaction  does  not  preclude 
the  further  use  of  arsphenamine ;  but  it  suggests  that 
careful  control  of  the  patient's  preparation  should  be 
exercised,  that  the  technic  should  be  reviewed,  and 
that  the  preparation  of  arsphenamine  should  be  inves- 


tigated. 


LATE     REACTIONS 


Lowering  of  General  Health:  Occasionally  during 
a  course  of  arsphenamine  a  patient's  general  health 
becomes  lowered  without  other  evidence  of  organic 
disturbance.  There  is  lassitude  and,  perhaps,  head- 
ache. The  appetite  is  poor  and  he  falls  off  in 
weight.  Such  symptoms  —  likely  to  be  overlooked 
because  of  their  insidiousness — should  lead  to  care- 
ful consideration  of  the  case.  Patients  who  are 
doing  well  under  specific  treatment  show  it  in  an 
improvement  in  their  general  well-being.  If  this 
lowering  of  the  health  progresses  under  arsphena- 
mine, it  should  be  discontinued.     The  patient  should 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       33 

stop  work,  be  placed  on  a  liberal,  perhaps  forced. 
diet,  given  tonics,  and  his  elimination  stimulated  by 
abundance  of  water  and  the  use  of  laxatives  or 
cathartics.  He  should  also  be  carefullly  examined  for 
other  diseases. 

Erythema  and  Dermatitis :  In  rare  cases,  patches  of 
scarlatiniform  erythema  develop  from  twelve  to 
twenty-four  hours  after  arsphenamine ;  these  are 
usually  accompanied  by  evidence  of  kidney  irritation. 
The  appearance  of  areas  of  scarlatiniform  erythema 
is  an  indication  that  arsphenamine  should  be  stopped 
until  well  after  these  symptoms  have  disappeared,  and 
that  its  further  use  should  be  very  guarded. 

These  preliminary  manifestations  of  intoxication 
usually  disappear  spontaneously  in  a  few  days, 
although  rarely  they  develop  into  the  severe  cases.  If 
arsphenamine  is  continued  in  spite  of  these  warnings, 
there  is  likely  to  develop  a  universal  exfoliative  der- 
matitis with  nephritis.  In  extreme  cases  the  nephritis 
is  severe,  accompanied  by  high  fever,  diarrhea  and 
bronchopneumonia,  and  the  result  may  be  fatal.  The 
same  measures,  to  a  greater  degree,  are  indicated  here 
as  already  suggested  for  lesser  intoxication — complete 
rest,  support  of  the  patient's  strength  by  an  abundant 
diet  and  stimulation  of  elimination. 


34  THE     VENEREAL     DISEASES 

Nephritis:  Severe  nephritis  with  its  sequelae  may 
occur  without  skin  symptoms.  For  this  reason  the 
urine  should  always  be  carefully  watched  while  ars- 
phenamine  is  given. 

As  already  suggested,  a  transient  albuminuria  with 
a  few  casts  is  common  the  next  morning  after  an 
injection  of  arsphenamine.  If  this  promptly  disap- 
pears, it  is  not  a  contraindication  to  the  continuance 
of  the  injections. 

Again,  albuminuria  due  to  syphilitic  nephritis  is  not 
very  rare.  The  evidence  of  the  characters  of  such  an 
albuminuria  is  that  it  is  quickly  benefited  by  arsphen- 
amine as  by  other  specific  treatment. 

Persistent  evidence  of  nephritis  developing  in  the 
course  of  arsphenamine  administration  is  another  mat- 
ter. It  requires  that  the  course  be  stopped  and  not 
resumed  until  the  nephritis  has  disappeared ;  and 
then  the  further  use  of  the  drug  must  be  with  extreme 
caution.  If  these  precautions  are  neglected  the  case 
is  likely  to  develop  into  one  of  severe,  permanently 
disabling,  or  fatal  type. 

Jaundice :  In  rare  cases,  jaundice  occurs  in  the 
course  of  the  use  of  arsphenamine.  It  is  always  a 
sign  of  serious  intoxication  and  should  cause  immedi- 
ate, careful  attention  to  be  given  to  the  case.  Such 
cases  may  go  on  to  acute  yellow  atrophy  of  the  liver 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       35 

with  fatal  termination.  They  require  in  the  way  of 
treatment  measures  for  overcoming  intoxication  of  the 
sort  already  outlined.  The  larger  proportion  of 
jaundice  cases  are  said  to  follow  neoarsphenamine. 

Hemorrhagic  Encephalitis :  This,  fortunately,  is  one 
of  the  rarest,  as  it  is  one  of  the  most  serious  of  ars- 
phenamine  accidents.  The  cases  begin  from  two  to 
four  days  after  arsphenamine  with  severe  headache, 
mental  confusion  and  dulness ;  then,  usually,  convul- 
sions, coma,  and  death  in  a  few  days. 

The  pathology  of  cases  succumbing  from  this  type 
of  arsenical  intoxication  shows  as  a  rule  the  following 
features :  There  is  characteristically  an  acute  hemor- 
rhagic encephalitis  with  softening  of  the  cerebral 
tissue  and  with  punctate  hemorrhages,  especially  in 
the  basal  ganglia,  pons  and  medulla,  but  also 
involving  the  cerebral  lobes  adjacent  to  the  lateral 
ventricles  and  less  frequently  the  cerebellar  tissue. 
With  this  is  associated  an  acute  ependymitis,  especially 
in  the  lateral  ventricles  with  hyperemia  and  punctate 
hemorrhages.  There  may  be  general  cerebral  con- 
gestion and  edema.  Acute  nephritis  may  be  present 
but  is  not  constant.  Degenerative  lesions  may  develop 
in  the  liver,  sometimes  giving  a  picture  resembling 
acute  yellow  atrophy. 


36  THE     VENEREAL     DISEASES 

Treatment  of  these  cases  consists  of  vigorous  elimi- 
nation, which  may  include  withdrawal  of  blood,  and 
the  intramuscular  use  of  epinephrin  in  full  doses. 

Herxheimer  Reaction :  In  the  presence  of  syphilitic 
lesions  in  vital  structures,  the  administration  of  ars- 
phenamine  which,  presumably  from  the  liberation  of 
spirochetal  endotoxins,  causes  a  temporary  engorge- 
ment of  the  syphilitic  lesion,  may  produce  serious  symp- 
toms of  pressure,  of  obstruction  or  of  other  impair- 
ment of  function.  This  reaction  is  most  likely  to  occur 
with  early  cerebral  lesions,  producing  pressure  symp- 
toms, which  may  cause  paralysis,  coma  and  even  death. 
As  a  rule,  while  the  symptoms  are  alarming,  recovery 
takes  place. 

Similar  reactions,  producing  symptoms  of  a  charac- 
ter dependent  on  the  location  of  the  syphilitic  focus, 
may  occur  with  syphilitic  lesions  of  the  viscera,  or  of 
the  circulatory  system,  particularly  in  myocarditic 
coronary  arteritis,  and  aortitis. 

To  guard  against  these  accidents,  when  there  is 
reason  to  suspect  lesions  in  any  of  these  structures, 
particularly  in  the  brain,  mercury  and  iodid  should  be 
vigorously  given  for  several  days  before  arsphenamine 
is  started,  if  the  symptoms  are  not  so  urgent  as  to  war- 
rant taking  the  risk  of  a  Herxheimer  reaction,  and 
then  the  use   of   arsphenamine   should  be  cautiously 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       37 

begun,  with  small  doses,  and  only  after  two  or  three 
injections  should  full  doses  be  given. 

In  these  reactions,  treatment  is  symptomatic. 

In  general,  the  careful  man  is  likely  to  attach  undue 
importance  to  minor  symptoms  arising  in  the  course 
of  arsphenamine  administrations,  and  to  be  influenced 
too  readily  by  them  to  give  up  its  use  in  the  particu- 
lar case.  On  the  other  hand  a  reasonable  caution  in 
the  face  of  symptomatic  warnings  of  arsphenamine 
intoxication  demands  care  in  its  further  use  in  such 
cases. 

XEURORECURRENCES 

It  is  an  occasional  experience  to  see,  with  patients 
who  have  had  insufficient  treatment  with  arsphenamine 
or  mercury,  a  recurrence  of  syphilis  in  a  nerve  or  the 
brain  or  cord,  producing  symptoms  of  impairment  of 
function  in  the  particular  structure  involved.  These 
recurrences  are  most  likely  to  be  observed  in  the  audi- 
tory or  optic  nerves,  producing  more  or  less  damage 
to  hearing  and  vision.  While  these  are  mentioned 
here,  they  are  not  manifestations  of  arsphenamine 
poisoning.  They  are  due  to  syphilitic  infiltrations  and 
occur,  as  well,  in  patients  who  have  had  no  arsphena- 
mine. They  require  vigorous  specific  treatment,  with 
mercury,    iodid,    and    arsphenamine  —  especially    the 


38  THE     VENEREAL     DISEASES 

latter  in  patients  who  have  already  had  arsphenamine. 
Of  course,  when  these  recurrences  are  cerebral  as  in 
the  case  of  involvement  of  the  optic  nerve,  due  care 
must  be  exercised  with  arsphenamine  to  avoid  a  Herx- 
heimer  reaction. 

TECHNIC     OF     ARSPHENAMINE     ADMINISTRATION 

The  fundamental  principle  of  administering  any 
form  of  arsphenamine  is  a  rigid  asepsis,  and  only 
extreme  conditions  justify  its  administration  when  this 
is  not  obtainable.  The  apparatus  should  be  boiled  for 
twenty  minutes.  It  is  important  that  freshly  distilled 
water  be  used  for  arsphenamine  solution.  Thirty  c.c.  of 
water  per  decigram  of  arsphenamine  is  a  safe  dilution. 
The  ampule  should  be  sterilized  by  immersion  in  a 
strong  antiseptic  solution,  such  as  mercuric  chlorid, 
1  :  1,000,  and  then  should  be  immersed  in  95  per 
cent,  alcohol  in  order  to  be  sure  it  is  not  cracked. 
If  it  has  been  immersed  in  mercuric  chlorid  it  must 
be  carefully  wiped  dry  before  it  is  opened.  It  must 
never  be  sterilized  by  boiling. 

The  drug  is  first  dissolved  in  about  50  c.c.  of  water. 
The  American  preparation  arsenobenzol  of  the  Phil- 
adelphia Research  Laboratories  requires  hot  water 
for  its  solution,  and  is  safely  dissolved  in  hot  water. 
The   other   preparations   dissolve   in   water   at   room 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       39 

temperature  and  should  not  be  heated,  because  of  the 
danger  of  the  formation  by  heat  of  highly  toxic  com- 
pounds. The  direct  solution  of  arsphenamine  is  a 
strongly  acid  solution,  which  must  be  neutralized  and 
diluted  before  injection.  Neutralization  is  accom- 
plished after  all  the  arsphenamine  is  dissolved  by  a 
15  per  cent,  freshly  prepared  solution  of  sodium 
hydroxid,  which  should  be  added  drop  by  drop. 
Arsphenamine  is  precipitated  from  the  solution  by  the 
alkali,  but  redissolves  as  soon  as  the  suspension  be- 
comes slightly  alkaline.  The  point  at  which  this  occurs 
can  be  gauged  with  sufficient  accuracy  if  the  sodium 
hydroxid  is  added  carefully  and  mixed  after  each 
drop  or  two.  Since  arsphenamine  oxidizes  easily,  it 
should  not  be  violently  shaken  in  preparation.  As  soon 
as  the  arsphenamine  has  redissolved,  yielding  a  clear 
yellow  solution,  it  may  be  filtered  through  wet  sterile 
cotton  in  a  funnel  directly  into  a  graduated  con- 
tainer ;  then  warm  or  cold  distilled  water  is  added 
to  the  proper  dilution  and  to  approximately  body 
temperature.  Care  must  be  taken  to  fill  the  tube 
attached  to  the  container  with  physiologic  sodium 
chlorid  solution  and  to  expel  all  air  bubbles  before  the 
arsphenamine  solution  is  filtered  into  the  container. 

In   the   event    that   the    arsphenamine   precipitates 
somewhat  on  dilution,  it  mav  be  redissolved  bv  another 


40  THE     VENEREAL     DISEASES 

drop  or  two  of  the  sodium  hydroxid.  If  the  prepara- 
tion has  been  made  too  strongly  alkaline,  a  drop  of 
dilute  hydrochloric  acid  may  be  added  and  the  neu- 
tralization repeated.  The  drug  should  be  adminis- 
tered promptly  after  preparation,  and  no  more  than 
enough  for  use  on  the  patients  to  be  treated  at  the 
time  should  be  prepared. 

The  technic  of  injection  of  the  solution  is  compar- 
atively simple,  and  the  older  custom  of  making  an 
incision  to  find  the  vein,  with  its  resultant  scarring, 
has  been  abandoned  by  skilful  operators.  A  variety 
of  needles  has  been  proposed,  but  the  Schreiber 
18-gage  with  thumb  guard  and  a  proper  adapter,  or 
even  a  plain  needle,  will  answer  all  purposes.  In  diffi- 
cult cases  a  finer  needle  may  make  it  much  easier  to 
get  in  the  vein.  The  skin  over  the  field  of  operation, 
preferably  in  the  region  of  the  large  cubital  veins,  is 
sterilized  as  for  a  surgical  procedure,  but  if  tincture 
of  iodin  is  employed  it  is  desirable  to  remove  it  with 
alcohol  in  order  that  the  vein  may  be  more  easily  seen. 
The  injection  should  be  given  with  the  patient  lying 
down  and  the  veins  distended  by  encircling  the  arm 
with  a  tourniquet. 

In  nervous  patients,  local  anesthesia  may  be  used  to 
advantage.  The  needle  is  pushed  directly  through  the 
skin  over  or  to  one  side  of  the  vein  and  then  intro- 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS      41 

duced  into  the  vein.  As  soon  as  the  blood  returns 
freely  through  the  needle,  the  adapter  attached  to 
the  tube  of  the  container  is  fitted  to  the  shoulder  of 
the  needle,  the  ton',  :  .i2r.z.  :s  released,  and  the  injection 
begun  by  elevating  the  container  about  two  feet.  As 
a  rule  assistance  is  desirable,  since  the  operator  is 
occupied  by  keeping  the  needle  in  position  in  the  vein. 
Failure  to  enter  the  vein  is  apparent  by  this  method, 
before  injection  is  begun,  through  the  imperfect  flow 
of  blood  through  the  needle.  The  saline  solution  con- 
tained in  the  tube  allows  sufficient  warning  of  the  infil- 
tration of  the  tissues  before  the  arsphenamine  solution 
reaches  the  needle  point.  Various  forms  of  apparatus 
which  inject  saline  solution  as  a  test  before  beginning 
the  injection  of  the  arsphenamine  are  not  essential  and 
are  often  complicated.  A  glass  telltale  in  the  rubber 
tube  permits  the  operator  to  watch  the  progress  of  the 
injection.  When  the  injection  is  completed,  the  low- 
ering of  the  container  below  the  level  of  the  arm 
before  the  needle  is  withdrawn  will  aspirate  a  small 
amount  of  blood  from  the  vein  and  prevent  the  escape 
of  solution  into  the  tissues. 

Recent  investigations  have  shown  that  the  danger 
from  intoxication  with  arsphenamine  is  much  greater 
when  it  is  administered  in  concentrated  solution  or  is 


42  THE     VENEREAL     DISEASES 

injected  rapidly.    For.  this  reason  it  should  be  used  in 
weak  dilution  and  slowly  injected. 

Infiltrates,  if  they  occur,  are  usually  trivial,  pro- 
vided the  operator  has  been  on  his  guard.  The  escape 
of  arsphenamine  into  the  subcutaneous  tissues  is  indi- 
cated by  a  burning  sensation,  which  the  patient  should 
be  warned  to  report.  The  reaction  which  ensues  when 
arsphenamine  is  injected  around  the  vein  is  inflamma- 
tory, with  induration  and  infiltration,  and  may,  if 
severe,  progress  to  a  slough.  Arsphenamine  infiltrates 
should  be  treated  by  wet  dressings,  icebag,  and  after 
inflammatory  symptoms  subside,  by  massage  and 
passive  movement.  An  alarming  degree  or  involve- 
ment may  subside  with  practically  no  damage  after 
several  weeks  or  months.  Thrombosis  of  the  vein  is 
an  infrequent  complication  if  the  drug  has  been  prop- 
erly diluted,  and  should  be  treated  on  general  indica- 
tions. 

THE     TECHNIC     OF     NEOARSPHENAMINE 
ADMINISTRATION 

The  original  administration  of  neoarsphenamine,  in 
dilutions  similar  to  those  used  with  arsphenamine,  has 
been  greatly  simplified  by  the  injection  of  the  dose  in 
concentrated  solution.  In  this  procedure,  the  dose  of 
neoarsphenamine  is  dissolved  in  10  c.c.  of  freshly  dis- 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS      43 

tilled  sterile  water  at  room  temperature — not  hot  water. 
The  solution  is  drawn  up  into  an  all-glass  syringe  and 
administered  as  an  intravenous  injection  after  the 
usual  preparations.  The  method  is  rapid  and 
extremely  convenient,  and  its  applicability  to  difficult 
cases  is  apparent. 

The  solution  of  neoarsphenamine,  being  already  neu- 
tral, requires  no  addition  of  sodium  hydroxid.  Care 
must  be  taken  to  avoid  infiltrates  with  the  concen- 
trated solution,  but  in  general  infiltrates  with  neoars- 
phenamin  are  apt  to  be  less  serious  than  those  with 
arsphenamine. 

MERCURY 

For  the  cure  of  syphilis,  arsphenamine  and  mer- 
cury should  be  combined,  and  at  the  same  time  with 
each  course  of  arsphenamine  a  vigorous  course  of  mer- 
cury should  be  given.  This  should  begin  before  or  at 
the  same  time  with  or  within  a  few  days  after  the  first 
dose  of  arsphenamine. 

A  course  of  mercury  should  consist  of  nine  or  ten 
weekly  injections  of  an  insoluble  salt,  of  from  twenty- 
four  to  thirty  injections  of  a  soluble  salt  at  two-day 
intervals,  or  of  from  forty  to  fifty  daily  inunctions  of 
mercurial  ointment.  The  administration  of  mercury 
either  by  inunction  or  by  intramusclar  injection  is 


44  THE     VENEREAL     DISEASES 

effective ;  and  in  the  selection  of  either  method  one 
may  be  properly  influenced  by  considerations  of  con- 
venience and  practicability. 

inunctions 

If  inunctions  are  used,  it  is  necessary  to  see  that 
they  are  properly  performed.  Patients  cannot  be 
trusted  to  give  themselves  inunctions ;  but  they  can 
very  readily  do  it  for  each  other  by  sitting  one  behind 
another  and  having  each  man  rub  the  back  of  the  man 
in  front  of  him.  From  4  to  8  gm.  of  mercurial  oint- 
ment may  be  used  for  a  daily  inunction.  It  is  desir- 
able before  the  inunction  to  wipe  off  the  area  to  be 
rubbed  with  alcohol  or  to  wash  it  lightly  with  soap 
and  water  and  dry.  The  ointment  should  be  rubbed 
in  slowly  and  gently  with  the  palmar  surface  for 
twenty  or  thirty  minutes,  or  until  the  ointment  is  prac- 
tically absorbed.  Any  excess  should  be  allowed  to 
remain  on  the  skin.  After  six  inunctions,  a  day  should 
be  skipped  and  the  patient  allowed  a  bath. 

In  giving  inunctions,  hairy  surfaces  and  the  thin 
skin  of  joints  should  be  avoided,  and  the  same  area 
should  not  be  used  often  enough  to  produce  dermatitis. 
The  two  sides  of  the  back  furnish  the  most  tolerant 
areas.  The  sides  of  the  abdomen  and  of  the  chest, 
and  the  inner  surfaces  of  the  thighs,  the  arms  and  the 
forearms  may  all  be  used. 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS      45 

INJECTIONS 

For  injections,  the  preferable  insoluble  preparations 
are  mercuric  salicylate  or  calomel  in  oil,  or  metallic 
mercury  in  the  form  of  gray  oil.  Perhaps  the  best 
proportion  for  the  salicylate  or  calomel  suspension  is 
20  gm.  (weight)  in  sterile  olive  oil  or  thin  liquid 
petrolatum,  enough  to  make  100  c.c.  (volume).  A 
good  formula  for  mercurial  oil  (gray  oil)  is  redis- 
tilled mercury,  20  gm. ;  chlorbutanol,  2  gm. ;  anhy- 
drous lanolin,  30  c.c.  and  liquid  petrolatum,  enough 
to  make  100  c.c. 

The  intramuscular  dose  of  calomel,  salicylate  and 
metallic  mercury  are  the  same.  These  three  prepara- 
tions, being  of  the  same  strength,  have  the  advantage 
of  having  the  same  dose.  The  average  dose  of  either, 
for  an  adult  man,  is  5  minims  (0.06  gm.,  1  grain) 
weekly ;  by  gradations  the  dose  may  be  increased  to 
0.12  gm.  (2  grains)  weekly,  or  with  caution  even 
higher. 

The  curative  action  of  the  injection  of  soluble  salts 
of  mercury  is  perhaps  less  than  that  of  the  insoluble. 
However,  they  are  free  from  the  dangers  of  cumula- 
tive effect  which  are  inherent  in  the  insoluble  salts ; 
and  in  emergencies,  when  there  is  need  to  get  prompt, 
certain  and  vigorous  effect  of  mercury,  they  are  of 


46  THE     VENEREAL     DISEASES 

great  value.  Mercuric  chlorid,  mercuric  succinimid 
or  mercuric  benzoate  are  the  most  useful  soluble  salts 
for  injections.  Good  preparations  are  1  or  2  per  cent, 
mercuric  chlorid  or  1  or  2  per  cent,  mercuric  succinimid 
with  1  per  cent,  sodium  chlorid  by  weight  in  distilled 
water.  The  average  dose  is  12  or  25  minims  (0.015 
gm.,  14  grain)  into  the  muscle  of  the  buttock  every 
second  day.  Mercuric  benzoate  is  given  in  2  per  cent, 
solution  with  2.5  per  cent,  sodium  chlorid,  average 
dose  12  minims  (0.015  gm.,  %  grain)  every  second 
day. 

The  American  Expeditionary  Forces  use  as  rou- 
tine treatment  intravenous  injection  of  1  per  cent, 
solution  of  mercuric  cyanid.  The  average  dose  is  1  c.c. 
(16  drops),  representing  0.01  gm.  (%  grain)  of  mer- 
curic cyanid,  given  daily. 

TECHNIC     OF     INJECTIONS 

For  intramuscular  injection,  a  syringe  such  as  the 
all-glass  Liier  hypodermic  syringe  with  a  U/2  inch,  20 
or  22  gage  needle  is  used.  The  needle  should  have  a 
slip  shoulder  to  permit  of  its  easy  detachment  from 
the  syringe.  Sterlization  of  the  skin  with  tincture 
of  iodin  is  sufficient ;  emulsions  once  sterilized  will 
remain  so  with  reasonable  care  in  their  handling.     In 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS      47 

military  service  the  syringe  and  needle  should  be  ster- 
ilized by  boiling,  or  by  liquid  phenol,  and  the  water  or 
phenol  removed  by  filling  the  syringe  first  with  alco- 
hol and  then  with  ether. 

The  site  of  the  injections  is  usually  in  the  upper 
outer  quadrant  of  the  buttock,  care  being  taken  to 
avoid  the  region  of  the  sciatic  nerve  or  the  structures 
about  the  hip  joint.  They  can  also  be  well  given  in 
the  upper  inner  quadrant  of  the  buttocks.  Injections 
are  made  alternately  into  each  buttock. 

The  needle  with  the  syringe  empty  should  be  intro- 
duced to  its  full  length,  and  the  syringe  then  detached 
and  filled  with  the  necessary  dose.  This  introduction 
of  any  empty  needle  is  a  safeguard  against  making  an 
injection  into  a  vein.  If  the  dry  needle  should  be  in 
a  vein,  on  detaching  the  syringe,  blood  would  well  up 
through  it;  if  the  needle  remains  free  from  blood,  as 
is  nearly  always  the  case,  there  is  reasonable  security 
against  introduction  into  a  vein. 

In  general,  in  order  to  prevent  leakage  of  the  emul- 
sion, it  is  desirable  to  introduce  the  needle  on  a  slight 
slant  in  the  tissue.  This  may  be  accomplished  by 
drawing  downward  on  the  skin  of  the  buttock,  which 
permits  a  valve  action  as  soon  as  the  needle  is  with- 
drawn and  the  hand  released.  The  injection  if  made 
slowly  is  practically  painless.     The  development  of 


48  THE     VENEREAL     DISEASES 

infiltrates  and  nodules  of  any  considerable  size,  or  in 
any  number,  during  a  course  of  injections,  is  either 
a  reflection  on  the  operator's  technic  or  shows  the 
case  to  be  unadapted  to  this  form  of  treatment. 
When  an  insoluble  salt  has  been  used,  each  of  these 
nodules  represents  encapsulated  mercury,  and  mate- 
rially increases  the  danger  of  cumulative  action. 
Daily  massage  by  the  patient  will  usually  reduce  them 
in  a  short  time.  If  their  formation  cannot  be  pre- 
vented the  patient  should  be  given  injections  of  a 
soluble  salt. 

CARE     OF     PATIENT     WHILE     TAKING     MERCURY 

Mercury  as  well  as  arsphenamine  throws  a  burden 
on  the  kidneys ;  and  patients  under  intensive  treat- 
ment with  mercury  and  arsphenamine  should  have  the 
renal  functions  carefully  watched.  An  examination  of 
the  urine  for  albumin  and  casts  should  be  made 
weekly,  and  the  development  of  definite  nephritis  dur- 
ing a  course  of  treatment  is  an  indication  to  stop. 
Treatment  may  be  undertaken  again  after  the  nephritis 
has  disappeared,  but  must  be  less  vigorous  than  before 
and  must  be  carefully  watched. 

Care  of  the  mouth  is  a  part  of  the  general  care 
which  a  syphilitic  should  have.  Dental  troubles 
should  be  looked  after  and  the  patient  instructed  in 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       49 

the  care  of  the  teeth.  When  a  syphilitic  patient  is  sent 
to  the  dentist,  the  dentist  should  without  fail  be 
notified  that  the  patient  has  syphilis  in  order  that  he 
may  safeguard  himself  against  infection.  A  dentifrice 
should  be  used,  and  it  is  a  good  plan  to  have  the 
patients  as  a  routine  use  an  oxidizing  mouth  wash 
such  as  a  one-half  saturated  potassium  chlorate  solu- 
tion, or  a  diluted  solution  of  hydrogen  peroxid.  When 
the  gums  are  soft  or  unhealthy,  a  good  astringent 
application  is  tincture  of  myrrh  to  be  painted  on  two 
or  three  times  daily,  after  brushing  the  teeth. 

SALIVATION 

If  salivation  occurs,  the  mouth  should  be  cleaned 
at  short  intervals  by  washing  with  hydrogen  per- 
oxid solution  or  half  saturated  potassium  chlorate 
solution.  Compound  solution  of  sodium  borate 
(Dobell's  solution)  may  also  be  used,  and,  while  less 
effective,  it  has  the  advantage  of  being  soothing. 
Pledgets  of  cotton  or  gauze  moistened  with  boric  acid 
solutions  placed  between  cheeks  and  teeth  give  comfort 
and  get  rid  of  exudate.  Atropin  is  useful,  given  to  the 
point  of  reducing  salivary  secretion.  If  the  patient  has 
been  using  inunctions,  he  should,  in  order  to  get  rid 
of  mercurv  in  the  skin,  be  greased  with  an  oil  and 
then   well   washed  with   soap  and   water   and   put   in 


50  THE     VENEREAL     DISEASES 

fresh  clothes.  He  should  have  a  soft,  nutritious  diet, 
be  protected  from  exertions,  and  given  the  care  for 
exhausting  illness.  In  particular,  he  should  be  given 
an  abundance  of  water. 

ESTIMATING     THE     COURSE     OF     CASES 

During  the  early  course  of  syphilis,  a  Wassermann 
test  should  be  made  at  monthly  intervals,  and  after  it 
has  apparently  become  permanently  negative,  it  should 
still  be  repeated  at  intervals  of  two  or  three  months 
for  at  least  a  year.  It  should  be  remembered  that  the 
Wassermann  test  is  not  likely  to  be  positive  for  the 
first  ten  days  of  the  chancre.  After  it  becomes  posi- 
tive, the  obtaining  of  a  single  subsequent  negative 
reaction  means  little ;  it  must  remain  negative  over  a 
period  of  months  to  justify  the  conclusion  that  it  is 
permanently  negative. 

In  estimating  the  effect  of  treatment  on  syphilis,  not 
only  the  disappearance  of  specific  clinical  symptoms 
and  of  the  positive  Wassermann  reaction  should  be 
considered,  but  the  patient's  general  well-being  as  well. 
In  zeal  to  sterilize  a  patient  of  spirochetes  the  effect 
of  the  treatment  itself  on  the  patient  should  not  be 
overlooked,  and  treatment  should  not  be  pushed 
beyond  the  point  at  which  the  patient  is  able  to  tol- 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       51 

erate  it  without  distinct  lowering  of  his  general  physi- 
cal tone. 

A  patient  may  be  regarded  as  free  from  the  neces- 
sity for  further  observations  or  treatment  who,  under 
observation  and  with  Wassermann  tests  at  intervals 
of  two  months,  has  remained  free  from  all  evidence  of 
syphilis  for  a  year. 

There  is  room  for  difference  of  opinion  as  to  the 
advisability  of  spinal  puncture  or  a  provocative  injec- 
tion of  salvarsan  with  a  subsequent  Wassermann  test 
in  every  case  before  discharge.  Conservative  practice 
reserves  the  use  of  these  diagnostic  measures  to  cases 
in  which  there  are  special  indications. 

LATE     SYPHILIS 

Late  syphilis  attacks  most  frequently  the  skin,  the 
bones,  the  nervous  system  and  the  vascular  system. 
The  lesions  in  the  skin  and  those  in  the  bones  usually 
present  clinical  pictures  which  are  characteristic  and 
should  be  recognized.  Tabes  and  paresis  are  mani- 
festations of  syphilis.  In  all  nervous  diseases — and 
particularly  cerebral  diseases — whose  symptoms  sug- 
gest the  gradual  occlusion  of  a  blood  vessel  or  the 
presence  of  a  tumor,  syphilis  should  be  at  once  care- 
fully considered.  Aortic  aneurysm  in  probably  all 
cases  and  most  cases  of  aortic  insufficiency  are  syphi- 


52  THE     VENEREAL     DISEASES 

litic.  Syphilis  not  infrequently  attacks  the  liver  and 
occasionally  the  other  abdominal  viscera.  It  very 
frequently  attacks  the  placenta  and  produces  abortion. 
Indeed  no  tissue  and  no  organ,  with  the  possible 
exception  of  the  prostate,  is  immune  to  syphilis;  and 
its  presence  must,  therefore,  always  be  regarded  as  a 
possibility  in  obscure  clinical  situations.  The  failure 
to  search  for  it,  including  the  taking  of  a  Wassermann 
test,  as  a  routine  procedure  in  cases  where  its  presence 
is  a  possible  factor,  leads  inevitably  to  important 
lapses  in  diagnosis. 

On  the  other  hand  there  is  a  tendency  to  magnify 
syphilis  into  an  all-prevailing  cause  of  disease  which 
is  not  justified.  Even  with  a  positive  Wassermann  in 
a  given  case,  the  preponderating  pathological  condi- 
tion has  to  be  determined  by  the  use  of  clinical  judg- 
ment. For  example,  many  cases  of  carcinoma  of  the 
mouth  occur  in  patients  who  have  syphilis  and  a  posi- 
tive Wassermann,  but  the  carcinoma  is  not  syphilis 
and  will  kill  the  patient,  if  the  time  for  operation  is 
lost  in  treating  him  for  syphilis.  It  is  rarely  true, 
however,  that  treatment  for  syphilis  will  do  a  patient 
harm,  if  other  necessary  measures  are  not  neglected ; 
so  that  it  is  a  safe  rule  to  treat  obscure  cases  for 
syphilis  if  there  is  a  positive  Wassermann  or  other 
reason  to  suspect  syphilis. 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       S3 

The  treatment  of  late  syphilis  is  with  mercury  and 
arsphenamine,  after  the  manner  outlined  already  for 
early  syphilis.  The  iodids  of  potassium  and  sodium 
are  also  of  the  greatest  use  for  the  late  lesions  and  are 
not  to  be  neglected  in  reliance  upon  arsphenamine. 
Either  of  these  iodids  should  be  given  well  diluted  in 
water — the  daily  dose  in  from  3  pints  to  3  quarts  of 
water — and  they  should  be  taken  after  meals.  When 
so  administered  they  rarely  cause  annoying  symptoms. 
Most  late  lesions  of  syphilis  are  readily  influenced  by 
moderate  doses,  H  to  2  grams  (8  to  30  grains),  of 
iodid  t.  i.  d.  But  the  amount  of  sodium  or  potassium 
iodid  that  can  be  taken  is  large ;  and  in  nervous  syphi- 
lis and  in  urgent  cases  the  iodid  should  be  given  in 
large  doses — 4  to  8  grams  (60  to  120  grains)  or  even 
more,  t.  i.  d. 

One  of  the  open  questions  in  syphilis  now  is  how 
persistently  treatment  with  arsphenamine  should  be 
pushed  in  the  effort  to  render  permanently  negative 
a  positive  Wassermann,  in  patients  whose  infections 
are  old — say  three  years  or  more — who  are  apparently 
healthy,  or  who  have  been  relieved  by  treatment  of 
other  evidences  of  syphilis  but  in  whom  a  positive 
Wassermann  persists.  In  general  it  may  be  said  that 
a    reasonable    effort    should   be    made    to    render    the 


54  THE     VENEREAL     DISEASES 

patient's  Wassermann  negative  by  repeated  courses  of 
arsphenamine  and  mercury.  But  that  this  effort  should 
not  be  pushed  without  regard  to  contraindications, 
such  as  have  been  pointed  out  in  the  consideration  of 
arsphenamine,  or  in  the  face  of  deterioration  of  the 
patient's  health  under  the  treatment. 


SUMMARY 

1.  For  the  cure  of  syphilis  it  is  of  the  greatest 
.mportance  that  the  initial  lesion  of  syphilis  be  recog- 
nized at  the  earliest  possible  moment. 

2.  To  this  end : 

(a)  Any  excoriation,  papule,  nodule,  crack,  "hair  cut,"  her- 
petic or  other  erosion — no  matter  how  small — as  well  as  any 
ilcer  about  the  genitals  or  elsewhere — if  there  is  any  reason 
:o  suspect  it — should  be  immediately  and  before  treatment  be 
■'xamined  for  the  Spirochaeta  pallida. 

(b)  No  lesion,  whether  a  chancre  or  only  suspected  to  be 
line,  should  be  treated  with  mercurial  or  other  antiseptics  or 
De  cauterized  either  with  chemicals  or  with  heat,  before  diag- 
nostic examination  for  the  spirochete  has  been  made. 

3.  Chancroids  should  be  suspected  of  harboring 
syphilis  until  repeated  examinations  for  the  Spiro- 
:haeta  pallida  and  repeated  Wassermanns  have  proved 
negative,  and  until  sufficient  time  has  elapsed  for  the 
ippearance  of  secondaries. 

4.  No  case  should  be  treated  for  early  syphilis  until 
a  positive  diagnosis  has  been  made  either  by  the 
demonstration  of  Spirochaeta  pallida  or  of  a  positive 
Wassermann  reaction. 

CLASSIFICATION 

1.  Primary  Stage:  Primary  lesion  present;  Spiro- 
chaeta pallida  present;  Wassermann  reaction  often 
negative ;  adenopathy  often  absent. 


56  THE     VENEREAL     DISEASES 

2.  Early  Stage :  First  twelve  months  after  primary 
stage. 

3.  Late  Stage :  Second  twelve  months  and  later. 


DRUGS 

Forms   and   Methods   of   Administration. — 1.  Ars- 
phenamine. 

(a)  Intravenous  only. 

(b)  Gravity  method  and  slowly  only. 

2.  Mercury. 

(a)  Forms. 

1.  Soluble. 

Bichlorid. 

Succinimid. 

Benzoate. 

2.  Insoluble. 

Salicylate  in  oil. 
Calomel  in  oil. 
Gray  oil. 

(b)  Injection  methods. 

1.  Soluble:    Into    the    subcutaneous    fat    or    into    the 

gluteal  muscles. 

2.  Insoluble :   Into   the   gluteal   muscles. 

3.  Iodids. 

(a)  Potassium. 
Sodium. 

(b)  Solution  by  mouth. 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       57 

DOSAGE 

1.  Arsphenamine. 

(a)  Normal  dosage  to  be  on  the  basis  of  1  decigram  to 
approximately  each  30  pounds  of  body  weight.  First 
dose  to  be  one  half  of  the  normal  dose,  that  is,  first 
dose  to  be  2  to  3  decigrams;  subsequent  doses  4 
to  6  decigrams. 

(b)  Dilution  to  be  not  less  than  25  c.c.  of  water  for  each 
decigram  of  arsphenamine. 

2.  Mercury. 

(a)  Soluble : 

1.  Xormal  dose  of  bichlorid  succinimid  or  benzoate, 

0.016  gm.  (1/A  grain)  every  second  day. 

2.  Solution  for  administration  to  contain  1   or  2  per 

cent,  of  bichlorid  or  succinimid  and  1  per  cent, 
sodium  chlorid,  or  2  per  cent,  benzoate  and  2.5 
per  cent,  sodium  chlorid,  dose  12  minims  of  2  per 
cent,  or  25  minims  of  1  per  cent,  solution,  0.016 
gm.   (%  grain). 

(b)  Insoluble: 

1.  Xormal    dose    of    salicylate,    calomel    or    gray    oil, 

0.064  gm.   (1  grain)   weekly. 

2.  Dilution : 

Salicylate,  calomel  and  metallic  mercury  to  be  in 
a  suspension  of  10  to  20  per  cent,  in  oil,  five 
drops  of  20  per  cent,  suspension  or  10  drops  of 
10  per  cent,  suspension  is  the  normal  dose  of  0.064 
gm.   (1  grain). 

(c)  The  dose  of  any  of  the  salts  may  be  increased  with 
caution. 


58  THE     VENEREAL     DISEASES 

3.  Iodids : 

1.  Standard  solution  contains  1  gm.  (15  grains)  of  sodium 

or  potassium  iodid  to  each  1  c.c.  of  water. 

2.  Dose  to  consist  of  10  to  100  drops  of  solution,  that  is, 

y2  to  6  gm.  (7.5  to  90  grains). 

3.  Administer  in  large  glass  of  water,  three  times  a  day. 

4.  Only    in    nervous    lesions    are    large    doses    of    iodids 

required.  From  1  to  3  gm.  (15  to  45  grains)  three 
times  a  day  are  sufficient  for  most  other  lesions  of 
syphilis. 

PATIENT 

1.  Examine  for  lesions  of  heart,  blood  vessels,  kid- 
neys and  other  viscera.  If  any  are  present,  administer 
arsphenamine  with  extreme  caution,  and  mercury 
carefully. 

2.  If  the  teeth  are  found  so  defective  as  to  require 
attention,  send  case  to  dentist  with  the  diagnosis. 

3.  Administration  of: 

1.  Arsphenamine : 

(a)  Examine  urine  for  albumin  before  each  adminis- 
tration. 

(b)  Give  on  an  empty  stomach. 

(c)  If  given  in  the  morning,  no  breakfast,  no  dinner. 

(d)  If  given  in  afternoon,  no  dinner,  no  supper. 

(e)  Rest,    preferably    in    bed,    until    morning    after 
administration. 

2.  Mercury: 

(a)  Examine  urine  for  albumin  and  casts  weekly. 

(b)  Watch  for  sore  mouth. 

(c)  Watch  for  salivation. 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS       59 

COURSES 

1.  Arsphenamine  and  mercury  to  be  given  together 
ivhen  indicated. 

2.  Arsphenamine : 

(a)  Each  course  to  consist  of  six  doses. 

(b)  Doses  to  be  administered  at  intervals  of  five  to  seven 
days. 

3.  Mercury : 

r(a)   Each  course  to  consist  of: 
1.  Soluble  forms,  twenty-four  to  thirty  injections. 
2.  Insoluble  forms,  nine  to  ten  injections 

(b)  Doses  may  be  cautiously  increased. 

(c)  Doses  to  be  administered  over  a  period  of  eight  to 
ten  weeks. 

4.  Iodids : 

(a)  Give  in  latent  syphilis. 

(b)  Give  when  tertiary  lesions  are  manifest. 

WASSERMANN    TESTS,    PERIODS    OF    REST    AXD    COURSES 
OF     TREATMENT 

Primary  and  Early  Stages.— First  Twelve  Months.— 
I  After  the  first  course  of  arsphenamine  and  mercury, 
•ive  the  patient  one  month's  rest. 

2.  At  the  end  of  one  month,  take  Wassermann ;  if 
Vassermann  is  positive,  repeat  the  complete  course; 
:  Wassermann  is  negative,  repeat  only  the  course  of 
lercury. 


60  THE     VENEREAL     DISEASES 

3.  At  the  end  of  the  second  course,  rest  two 
months ;  then  give  third  course  in  accordance  with  the 
Wassermann  conditions  as  outlined  in  first  course. 

4.  Three  courses  with  intervals  of  rest  carry  the 
patient  through  the  first  year  of  treatment. 

Late  Stage. — Second  Twelve  Months  and  Later. — 
1.  During  the  second  year,  if  Wassermann  remains 
positive,  repeat  complete  courses  of  treatment  with 
intervals  of  rest  of  two  months. 

2.  During  the  second  year,  if  Wassermann  is  nega- 
tive, give  two  courses  of  mercury  with  intervals  of 
four  months. 

SCHEMA 

First    Year 

First  course  of   treatment 2  to  2V2  months 

Rest !        month 

Second  course  of  treatment 2  to  2%  months 

Rest   2       months 

Third   course   of   treatment 2  to  2\f%  months 

.  Second    Year 
(If  Wassermann  is  negative) 

Rest  after  third  course    4  months 

Course  of  mercury    2  months 

Rest 4  months 

Course   of   mercury    2  months 

Second    Year 
(If  Wassermann  is  positive) 
If   Wassermann  remains  positive,     complete     courses 
of   treatment  should   be   given    with     intervals    of    rest 
of  two  months  each. 


DIAGNOSIS    AND    TREATMENT    OF   SYPHILIS      61 

TREATMENT     OF     LATE     SYPHILITIC     LESIONS 

These  are  to  be  treated  by  one  or  more  courses  of 
mercury  or  mercury  and  arsphenamine  given  in  the 
same  way  as  indicated  for  early  syphilis.  The  use  of 
mercury  and  arsphenamine  in  lesions  should  be  com- 
bined with  that  of  the  iodids. 


CHANCROID 


Chancroid,  more  than  gonorrhea  or  syphilis,  is  a 
disease  of  the  careless  and  dirty.  It  is  relatively 
uncommon  among  clean  people.  It  is  readily  pre- 
vented by  prompt  prophylactic  treatment:  simple 
washing  with  soap  and  water  after  coitus  greatly 
reduces  the  risk  of  infection  with  it. 

Diagnosis. — Always  in  the  presence  of  chancroid,  a 
careful  search  should  be  made  to  determine  whether 
or  not  there  is  also  an  infection  with  syphilis.  In  a 
very  considerable  proportion  of  cases,  there  is.  One 
cannot  rest  safe  with  a  diagnosis  of  chancroid,  even 
when  repeated  examinations  fail  to  discover  the 
Spirochaeta  pallida.  The  incubation  period  of  the 
chancre  is  from  two  to  three  weeks  longer  than  that 
of  the  chancroid,  and  it  may  emerge  only  in  the  heal- 
ing chancroid,  and  then  escape  detection.  Every  chan- 
croid must  be  regarded,  therefore,  as  a  potential  case 
of  syphilis ;  in  addition  to  repeated  examinations  for 
spirochetes,  Wassermann  tests  should  be  made  at 
weekly  intervals  for  six  weeks,  and  the  patient  kept 
under  observation  for  syphilis  for  two  months. 

General  Treatment. — In  order  to  hasten  recovery, 
the  patient  with  chancroid  should  be  put  to  bed,  kept 


CHANCROID  63 

clean,  and  given  a  nourishing  diet.  Rest  not  only 
makes  for  a  prompt  healing  of  the  chancroid,  but 
greatly  reduces  the  danger  of  bubo.  Destructive  chan- 
croids are  seen  in  the  dirty  and  debilitated.  If 
patients  with  chancroids  are  kept  clean  and  well  nour- 
ished, healing  is  usually  prompt,  and  extensive  ulcera- 
tion very  rarely  seen. 

Local  Treatments. — Abortive  Treatment:  In  a  cer- 
tain proportion  of  cases  of  chancroid,  abortive  treat- 
ment is  successful.  The  principle  of  all  methods  of 
abortive  treatment  is  to  convert  the  infected  ulcer  into 
a  sterile  one  by  the  use  of  some  destructive  agent. 
This  may  be  either  the  actual  cautery,  or  one  of  sev- 
eral strong  chemical  caustics. 

The  thermocautery  is  perhaps  the  best  agent  for 
this  treatment.  The  ulcer  is  thoroughly  cleaned  and 
well  dried.  Then  the  entire  area  of  it  is  seared  with 
a  cherry  red  cautery.  Every  particle  of  diseased  tis- 
sue must  be  destroyed.  It  should  be  done  under  a 
general  anesthetic,  preferably  gas. 

Chemical  cauterization  is  done  as  follows :  The 
ulcer  is  well  cleaned,  being  first  irrigated  and  then 
dried.  Then  a  pledget  of  cotton  wet  with  5  to  10  per 
cent,  solution  of  cocain  hydrochlorate  or  procain  is 
applied  to  it.     After  anesthesia  is  produced  the  ulcer 


64  THE     VENEREAL     DISEASES 

is  dried  as  thoroughly  as  possible,  preferably  with 
blotting  paper,  in  order  to  prevent  the  running  of  the 
chemicals  subsequently  to  be  applied.  After  it  has 
been  thoroughly  dried,  the  entire  surface  of  the  ulcer, 
both  edges  and  base,  is  touched  with  pure  liquid  phe- 
nol (carbolic  acid)  applied  on  a  small  cotton  swab, 
care  being  taken  to  let  no  infected  point  escape.  Then 
the  excess  of  phenol  on  the  surface  is  taken  up,  and 
nitric  acid  is  applied  lightly  in  the  same  way.  The 
ulcer  should  be  flushed  immediately  with  sterile  water 
to  stop  the  action  of  the  acid.  Instead  of  nitric  acid 
a  saturated  solution  of  zinc  chlorid  can  be  used.  This 
is  as  active  a  caustic  as  nitric  acid,  and  its  action 
should  be  stopped  as  quickly  after  application  by 
flushing  with  water. 

After  cauterization  in  any  of  these  ways,  the  wound 
should  be  dressed  with  cold  compresses  of  boric  acid 
solution  or  similar  bland  solution.  There  results  an 
acute  inflammatory  reaction,  the  slough  is  thrown  off, 
and  in  successful  cases,  a  healthy  granulating  surface 
is  left. 

The  advantage  of  these  methods  of  treatment  is  that, 
in  successful  cases,  healing  takes  place  quickly  and 
the  danger  of  bubo  is  almost  eliminated.  Their  suc- 
cess depends  on  thoroughness  in  destroying  the 
infected  area.     If  the  procedure  fails  to  do  this  com- 


CHANCROID  65 

pletely,  it  does  harm,  because  it  produces  a  larger 
ulcer  which  becomes  infected  from  the  focus  of 
disease  that  has  been  left.  Attempts  at  abortive 
treatment  with  superficial  caustics,  such  as  silver 
nitrate,  are  always  failures.  Attempts  at  abortive 
treatment  should  not  be  made  unless  the  prospects  of 
complete  destruction  of  the  diseased  tissue  are  good. 
Abortive  treatment  is  contraindicated  under  the  fol- 
lowing conditions: 

1.  When  the  diseased  area  or  areas  are  so  extensive 
or  so  situated  that  the  destruction  produced  by  this 
treatment  would  result  in  considerable  deformity.  The 
chief  situation  in  which  it  is  contraindicated  is  in 
chancroid  at  the  meatus. 

2.  When  the  inflammatory  reaction  is  already 
intense  and  there  is  much  edema.  These  would  be 
increased  by  cauterization. 

3.  When  there  is  inguinal  adenitis.  This  would  be 
aggravated  by  cauterization. 

4.  In  healing  chancroids.  Here  the  infection  is 
already  under  control  and  nothing  would  be  gained  by 
cauterization. 

Abortive  treatment  will,  of  course,  interfere  with 
any  further  search  for  spirochetes.  For  this  reason 
it  should  never  be  undertaken  until  every  reasonable 
effort  to   find   the   spirochetes  has  been   made      The 


66  THE     VENEREAL     DISEASES 

early  diagnosis  of  syphilis  is  so  much  more  important 
than  the  prompt  healing  of  a  chancroid,  that  efforts  to 
heal  the  chancroid  should  be  given  no  consideration 
until  the  question  of  diagnosis  is  settled  as  far  as  pos- 
sible. And  after  successful  abortive  treatment,  there 
should  be  no  relaxation  in  the  weekly  Wassermann 
tests  or  in  the  clinical  observations  until  syphilis  can 
be  finally  ruled  out. 

In  all  cases,  except  those  favorable  for  abortive 
treatment,  reliance  is  placed  on  cleanliness,  the  use  of 
antiseptics,  and  measures  to  promote  healing.  The 
first  principle  in  treating  chancroids  is  to  keep  them 
as  free  as  possible  from  pus,  both  to  promote  healing 
of  the  ulcer  and  to  prevent  infection  of  the  lymphatics. 
In  all  cases,  for  the  effect  of  the  heat  as  much  as  for 
cleaning  effect,  the  patient  should  hold  the  penis  in 
hot  water  for  half  an  hour  several  times  daily.  Then 
the  lesion  should  be  given  a  copious  warm  irrigation 
with  boric  acid  solution  or  mercuric  chlorid,  1 :  10,000, 
or  potassium  permanganate,  1 :  3,000,  or  some  other 
nonirritating  antiseptic  solution.  Then  the  ulcer 
should  be  dusted  with  an  antiseptic,  such  as  iodoform 
(the  preferable  antiseptic),  thymol  iodid,  calomel  or 
argyrol.  After  this  there  should  be  applied  a  moist  j 
dressing  of  one  of  the  solutions  which  are  used  for] 
irrigating  the  ulcer.    In  very  acute  cases,  a  good  dress- 


CHANCROID  67 

ing  is  one  wet  with  aluminum  acetate  solution,  one 
part  of  the  8  per  cent,  solution  of  aluminum  acetate  to 
seven  or  fifteen  of  water.  The  dressings  must  be 
kept  continually  moist  and  changed  frequently  enough 
to  prevent  accumulation  of  pus  on  the  ulcer. 

When  for  any  reason  it  is  impracticable  to  keep  a 
wet  dressing  constantly  applied,  the  next  best  course 
:o  pursue  is  to  dust  the  ulcer  after  irrigation  with 
irgyrol  crystals  or  iodoform  and  then  cover  it  with 
jauze,  spread  with  petrolatum.  Dry  powders  alone 
ire  not  good  applications  for  chancroids.  They  cake 
nto  crusts,  under  which  the  pus  accumulates,  and  this 
naterially  increases  the  risks  of  infection  of  the  lym- 
phatics and  the  occurrence  of  bubo. 

Occasionally  in  the  course  of  healing  of  chancroids, 
he  granulations  become  sluggish ;  in  such  cases,  stim- 
llation  by  the  application  of  balsam  of  Peru  works 
veil,  or  the  granulations  may  be  touched  occasionally 
nth  silver  nitrate.  If  there  is  an  overgrowth  of  the 
mhealthy  granulations,  they  should  be  trimmed  off 
Kh  a  knife  or  razor  or  seared  with  a  cautery,  and 
ben  dressed  with  iodoform  and  a  wet  compress. 

In  chancroids  under  a  greatly  swollen  or  long,  tight 
repuce,  wet  dressings  cannot  be  used.  In  these  ca^es 
rolonged  soakings  in  hot  water  several  times  dailv  are 
articularly  serviceable.     After  each  soaking  the' pre- 


68  THE     VENEREAL     DISEASES 

putial  sac  should  be  cleaned  by  inserting  into  it  a 
catheter  or  a  long  flat  syringe  nozzle  and  thoroughly 
irrigating  with  hot  antiseptic  solution.  After  the  irri- 
gation there  should  be  injected  into  the  preputial  sac 
from  2  to  4  c.c.  of  a  suspension  of  antiseptic  powder 
in  oil  or  glycerin,  such  as  20  per  cent,  calomel,  10 
per  cent,  thymol  iodid  or  10  per  cent,  iodoform  in  oil 
or  glycerin.  Of  these,  10  per  cent,  iodoform  in 
glycerin  is  best. 

In  patients  with  a  long  prepuce  it  is  best  not  to  make 
a  dorsal  slit,  if  progress  can  be  made  without  so  doing; 
for  if  a  dorsal  slit  is  made,  the  whole  surface  at  once 
becomes  chancroidal.  Not  infrequently  in  cases  with 
intense  reaction  and  great  swelling  no  headway  can 
be  made  while  the  prepuce  is  intact;  in  other  cases 
the  reaction  becomes  so  exaggerated  that,  unless  relief 
of  tension  is  given,  sloughing  of  the  prepuce  will 
occur.  Under  these  conditions  a  linear  slit  along  the 
dorsum  of  the  prepuce  should  be  made,  and  the  case 
then  treated  as  an  open  chancroid.  A  complete  circum- 
cision should  never  be  attempted  until  the  infection  has 
entirely  disappeared. 

BUBO 

Under  the  usual  conditions  of  treatment  of  chan- 
croids, when  patients  are  not  in  bed,  suppurative  in; 


CHANCROID  69 

guinal  adenitis  occurs  in  from  30  to  50  per  cent,  of  the 
cases.  But  the  factors  that  predispose  to  bubo  are 
muscular  activity  and  accumulation  of  pus  on  the 
chancroid;  so  that  with  patients  in  bed  and  with  their 
chancroids  kept  free  from  pus,  bubo  is  a  relatively 
infrequent  complication. 

When  bubo  threatens,  extra  care  should  be  used  to 
see  that  there  is  no  absorption  of  pus  from  the  chan- 
croid; the  patient  should  have  complete  rest;  and  hot 
applications  should  be  applied.  If  fluctuation  devel- 
ops, the  hot  applications  are  continued  until  the  gland 
has  fully  broken  down.  When  it  is  soft  throughout 
and  full  of  pus,  a  small  incision  with  a  double  edge 
knife  should  be  made,  and  the  pus  evacuated.  Iodo- 
form glycerin,  10  per  cent.,  is  then  injected  into  the 
cavity.  The  emulsion  should  be  injected  three  times  at 
the  first  sitting.  The  first  two  injections  run  out  and 
the  last  one  remains  in.  The  wound  is  then  bandaged 
with  gauze,  moistened  with  solution  of  aluminum 
acetate,  one  part  in  seven  of  water,  or  boric  acid  solu- 
tion, or  some  other  antiseptic  solution.  On  the  follow- 
ing day,  the  wound  is  emptied  by  squeezing,  and  iodo- 
form emulsion  injected  once  and  left  in.  The  bandage 
is  then  applied,  and  in  five  or  six  days  the  wound  is 
closed  and  healed.     If  after  a  week  the  wound  is  not 


70  THE     VENEREAL     DISEASES 

closed,  it  should  be  injected  again;  this  will  usually 
result  in  healing  in  five  or  six  days. 

The  method  of  injecting  the  wound  with  silver 
nitrate  solution  has  been  abandoned  on  account  of  the 
pain  that  it  causes  and  because  it  is  no  better  than  the 
injection  with  iodoform. 

The  plan  of  encouraging  suppuration  and  evacuat- 
ing the  pus  through  a  small  incision  is  satisfactory  in 
most  cases  when  the  glands  break  down  rapidly.  But 
sometimes  suppuration  goes  on  very  slowly;  and  in 
these  cases,  it  is  better  to  make  a  free  incision,  evacu- 
ate the  pus,  and  dissect  or  curet  out  the  partially 
broken-down  remains  of  the  glands.  Then  the  wound 
is  packed  with  gauze  and  allowed  to  heal  by  granula- 
tion. It  is  better  to  avoid  this  course  if  possible,  as 
the  subsequent  healing  takes  six  or  eight  weeks,  and 
requires  daily  dressing. 

It  was  the  practice  a  few  years  ago  to  endeavor  to 
prevent  suppuration  in  the  glands  by  dissecting  them 
out  and  trying  to  get  a  clean  wound  which  was  closed 
by  suture.  This  practice  has  now  been  abandoned 
because  it  was  found  that  a  solid  edema,  or  elephanti- 
asis, of  the  penis  and  scrotum  and  inguinal  region 
often  followed,  in  consequence  of  the  obliteration  of 
the  lymphatic  vessels  in  the  area  of  the  wound. 
Another  objection  was   that,  when  patients  came  to 


CHANCROID  71 

operation,  suppuration  had  nearly  always  begun  in 
the  center  of  the  gland,  even  though  no  fluctuation 
was  evident ;  the  wound  was  not  aseptic  and  could  not 
be  closed,  but  had  to  be  left  open  for  the  slow  process 
of  healing  by  granulation. 


BALANITIS     GANGRENOSA 


EROSIVE     OR     GANGRENOUS     BALANITIS 

In  connection  with  chancroid  attention  is  called  to 
this  venereal  infection,  which  while  rare  is  important, 
because  of  its  destructive  course,  if  unrecognized  and 
treated  as  chancroid. 

Balanitis  gangrenosa  is  an  affection  which  begins  as 
small  whitish  excoriations,  situated  in  the  coronary 
sulcus  or  on  the  adjacent  part  of  the  glans  or  prepuce. 
They  always  occur  under  a  long  prepuce.  These 
excoriations  develop  into  superficial  small  round  ulcers, 
which  coalesce  into  larger  polycylic  ulcers.  The  ulcers 
are  covered  by  a  closely  adherent  necrotic  membrane 
and  bleed  easily  on  its  removal.  They  discharge  an 
abundant  offensive  thin  yellowish  or  brownish  pus. 
The  lesions  may  heal  without  extending  beyond  the 
stage  of  excoriation,  but  more  frequently  they  form 
gangrenous  ulcers.  When  this  occurs  destruction  is 
very  rapid.  If  the  ulcer  is  situated  on  the  inner  sur- 
face of  the  prepuce,  it  may  be  visible  as  a  dark  area 
through  the  prepuce  and  is  likely  to  cause  quick 
sloughing  of  it.  Situated  on  the  glans  it  rapidly 
destroys  it.     It  may  spread  quickly  to  the  shaft  and 


BALANITIS     GANGRENOSA  73 

cause  partial  destruction  of  the  penis  or  even  its  com- 
plete amputation  down  to  the  pubis. 

Lymphangitis  and  inguinal  adenitis  occur  both  with 
the  erosive  and  gangrenous  forms,  but  the  glands  do 
not  suppurate  as  they  do  in  chancroid. 

Both  in  erosive  and  gangrenous  balanitis,  the  parts 
are  extremely  sensitive,  but  urination  is  not  painful 
except  when  phimosis  causes  distention  of  the  pre- 
putial sac  with  urine.  Systemic  symptoms  are  usually 
absent  or  trivial.  Even  in  the  gangrenous  cases,  sepsis 
is  slight.  Occasionally  the  symptoms  are  more 
marked,  and  there  may  be  a  temperature  of  103  or 
104  F. 

ETIOLOGY 

The  disease  is  produced  by  a  symbiosis  of  a  spirillum 
and  a  vibrio  identical  with  those  producing  Vincent's 
angina  and  noma.  It  may  be  the  same  infection  that 
produces  hospital  gangrene.  TunniclifT,  from  her 
studies  of  Vincent's  angina,  believes  that  the  spirillum 
and  vibrio  are  the  same  organisms,  occurring  in  dif- 
ferent forms  under  different  conditions.  The  vibriones 
are  curved  rods  with  pointed  ends,  about  2  microns 
long  and  0.8  of  a  micron  in  width.  They  stain  with 
ordinary  dyes  and  are  gram-positive,  but  require  care- 
ful decolorization  with  70  per  cent,  alcohol.  The 
spirilla  occur  as  loose  wavy  spirals  and  are  6  to  39 


74  THE     VENEREAL     DISEASES 

microns  long  and  0.2  of  a  micron  broad.  They  move 
rapidly  with  a  quick  back  and  forward  snake-like 
movement.  They  stain  with  the  ordinary  dyes  and  are 
gram-negative.  The  vibriones  may  be  cultivated  on 
serum  agar.  They  are  anaerobic  and  are  found  in  the 
deeper  part  of  the  necrotic  tissues.  The  spirilla  which 
are  less  abundant  are  found  in  the  superficial  lesions. 
The  spirilla  occur  as  saprophytes  in  the  mouth,  and  the 
infection  probably  originates  most  frequently  from  the 
saliva.  The  spirilla  are  not  pathogenic,  except  in  asso- 
ciation with  the  vibriones  and  under  anaerobic  condi- 
tions or  in  patients  with  greatly  lowered  resistance. 

DIAGNOSIS 

The  presence  of  erosive  or  gangrenous  lesions  near 
the  corona  under  a  long  prepuce,  the  peculiar  bad 
smelling  yellowish  or  brownish  purulent  discharge, 
and,  in  the  gangrenous  cases,  the  rapid  destruction  are 
characteristic  clinical  features  distinguishing  the  condi- 
tion from  chancroid.  In  addition,  the  vibriones  and 
spirilla  are  demonstrable  in  the  discharge  and  in  the 
tissues.  The  inflammatory  reaction,  the  edema  of  the 
prepuce,  and  the  degree  of  phimosis  are  greater  than  in 
chancroid.  There  is  moderate  enlargement  of  the 
inguinal  glands,  but  they  are  painless  and  do  not  sup- 
purate,  as   they  usually   do  with   a   long  prepuce   in 


BALANITIS     GANGRENOSA  75 

chancroid.  As  with  chancroid,  the  lesions  may  mask 
syphilitic  infection,  and  the  cases  require  watching 
subsequently  for  syphilis,  in  the  same  manner  as  do 
cases  of  chancroid.  Prompt  recognition  of  the  infec- 
tion is  important,  because  of  the  destruction  which 
may  quickly  result  if  its  character  is  not  recognized 
and  prompt  treatment  instituted.     . 

TREATMENT 

The  key  to  treatment  lies  in  the  fact  that  the  organ- 
isms are  pathogenic  only  under  anaerobic  conditions. 
The  lesions  must  be  exposed  so  that  oxygen  can  reach 
them,  or  their  spread  cannot  be  controlled.  The  glans 
must  be  completely  uncovered  by  a  dorsal  slit  of  the 
prepuce.  After  this,  the  affected  parts  should  be  left 
without  occlusive  dressings  and  frequently  washed 
with  hydrogen  peroxid  solution.  The  best  measure  is 
continuous  irrigation  with  dilute  hydrogen  peroxid 
solution.  With  exposure  of  the  lesions  to  the  air  and 
the  use  of  hydrogen  peroxid,  healing  is  usually  rapid. 


THE  TREATMENT  OF  GONORRHEA 


GENERAL     CONSIDERATIONS 

The  earlier  cases  of  acute  gonorrhea  are  seen,  the 
better  are  the  chances  for  rapid  cure  and  the  less 
the  dangers  of  posterior  urethritis  and  the  complica- 
tions of  gonorrhea.  With  gonorrhea,  as  with  syphilis, 
persons  should  be  encouraged  to  report  on  the  slight- 
est suspicion  of  trouble,  and  those  who  have  been 
exposed  should  be  watched  for  a  week  for  manifes- 
tation of  the  disease.  On  its  appearance,  treatment 
should  be  instituted  immediately.  Every  patient  with 
acute  urethritis  should  be  placed  at  rest  at  once. 

The  patient  should  be  given  instructions,  preferably 
printed,2  on  the  part  he  must  take  in  the  conduct  of  his 
case.  In  all  cases  he  must  be  warned  of  the  danger 
of  carrying  the  disease  to  his  eyes,  and  of  gonorrheal 
ophthalmia ;  and  of  the  necessity  of  washing  his  hands 
after  touching  his  penis  or  anything  contaminated  with 
his  pus. 

At  the  first  examination  of  every  case  of  gonorrhea, 
the  patient  should  be  stripped  in  order  to  permit  a  gen- 


2.   See  page   157   for  an   example  of   such  instructions. 


TREATMENT  OF  GONORRHEA        77 

eral  survey  of  his  condition.  Xote  should  be  made  of 
the  amount  of  discharge  and  of  the  condition  of  the 
glans  and  prepuce.  Smears  of  the  urethral  discharge 
should  be  made  on  a  cover  glass  for  microscopic 
examination.  The  presence  or  absence  of  chancre 
and  chancroid  should  be  determined.,  and  the  testicles 
should  be  examined  for  a  beginning  epididymitis. 
Then  the  patient  should  be  instructed  to  pass  his  urine 
into  two  glasses. 

Two-Glass  Test. — The  two-glass  test  should  be  made 
at  each  examination  for  the  purpose  of  watching  the 
progress  of  the  case  by  determining:  (a)  if  the  pos- 
terior urethra  has  become  affected;  (b)  the  amount 
of  pus  secreted. 

The  urine  passed  during  gonorrhea  appears  turbid 
from  admixture  with  pus,  in  which  are  little  clumps  or 
masses  of  desquamated  epithelium.  After  standing, 
the  pus  settles  to  the  bottom  of  the  glass  and  a  cloud 
of  mucus  appears  floating  above  it.  As  the  patient 
goes  on  toward  recovery,  the  pus  disappears,  but  the 
hypersecretion  of  mucus  continues  and  occasions  a 
cloudiness  of  the  urine,  giving  it  a  mucilaginous 
appearance.  After  the  mucus  disappears,  the  "clap- 
shreds"  persist  for  months,  because  isolated  portions 
of  mucous  membrane  are  not  covered  with  epithelium 
and  are  still  secreting  pus. 


78  THE     VENEREAL     DISEASES 

In  the  two-glass  test,  if  the  anterior  urethra  alone  is 
affected,  the  first  glass  of  urine  will  be  cloudy  and  the 
second  glass  clear;  but  if  the  posterior  urethra  is 
involved  both  glasses  will  be  turbid  from  the  presence 
of  pus.  These  findings  are  accounted  for  by  the  action 
of  the  cut-off  muscle  which  forms  a  barrier  between 
the  anterior  and  posterior  urethra.  It  prevents  pus  in 
the  anterior  urethra  from  flowing  back  into  the  blad- 
der ;  so  that  in  anterior  urethritis  alone,  the  pus  in  front 
of  the  cut-off  muscle  is  washed  out  in  the  first  flow  of 
urine,  while  the  last  of  the  urine  will  flow  over  a  clean 
surface  and  remain  clear ;  that  is,  the  first  glass  will  be 
turbid,  the  second  clear.  On  the  other  hand,  in  pos- 
terior urethritis,  the  cut-off  muscle  holds  back  the  pus, 
as  it  does  the  urine  in  the  bladder,  and  the  pus  flows 
back  into  the  bladder  and  renders  all  the  urine  turbid. 
When  the  urine  in  posterior  urethritis  is  passed  into 
two  glasses,  the  second  glass  is  turbid  as  well  as  the 
first.  If  it  is  desired  to  determine  the  condition  of  the 
anterior  urethra  in  posterior  urethritis,  it  can  readily 
be  done  by  irrigating  the  anterior  urethra  with  saline 
solution  and  collecting  the  washings  in  a  glass  for 
inspection. 

Microscopic     Examination     of     Pus. — Microscopic 
examinations  of  pus  are  indispensable,  not  merely  for 


TREATMENT  OF  GONORRHEA        79 

the  establishment  of  a  diagnosis  of  urethritis  caused 
by  the  gonococcus  from  that  caused  by  some  other 
organism,  such  as  the  colon  bacillus,  a  staphylococcus 
or  a  streptococcus,  but  also  for  the  observation  of 
the  progress  and  stage  of  the  disease,  for  the  selec- 
tion of  the  appropriate  treatment  for  the  different 
stages,  and  finally  for  the  purpose  of  determining 
whether  the  gonococci  have  been  eliminated  and  the 
patient  cured. 

THE   GONOCOCCUS 

The  gonococcus  is  coffee-bean  or  kidney  shape,  and 
is  usually  found  in  diplococcus  form,  the  flat  or  slightlv 
indented  side  of  the  organisms  facing  each  other.  In 
pus  from  acute  gonorrhea  organisms  are  found  both 
within  and  without  the  cells,  crowded  in  masses  in  the 
leukocytes.  The  intracellular  location  of  the  organisms 
is  of  diagnostic  importance,  but  it  is  not  so  character- 
istically seen  in  pus  from  chronic  cases. 

The  gonococcus  is  easily  stained  with  methylene-blue 
or  with  most  of  the  other  anilin  dyes.  It  is  a  gram- 
negative  organism,  and  for  the  purpose  of  differentia- 
tion from  other  diplococci  a  Gram  stain  is  necessary. 
It  is  quickly  decolorized  by  Gram's  method  and  can 
then  be  counterstained  with  safranin  or  fuchsin  or 
other   stain.      The    Gram    stain    does    not    furnish    sn 


80  THE     VENEREAL     DISEASES 

absolutely  characteristic  differentiation  of  the  gono- 
coccus  from  all  similar  cocci,  but  in  pus  from  the 
urethra  or  vagina,  or  from  the  eye  in  cases  of  acute 
conjunctivitis,  it  may  be  accepted  as  a  reliable  test. 

For  the  absolute  differentiation  of  the  gonococcus 
cultural  methods  are  necessary. 

In  the  prodromal  stage  when  the  discharge  from  the 
meatus  is  thin  and  scanty,  microscopic  examination  of 
smears  shows  quantities  of  desquamated  cylindric 
epithelial  cells  and  a  moderate  number  of  pus  cells 
containing  clumps  of  intracellular  gonococci.  In  the 
ascending  stage  a  large  number  of  pus  cells,  many  of 
them  containing  gonococci,  and  a  number  of  free 
gonococci  are  to  be  seen.  The  stage  of  decline  is  indi- 
cated by  the  appearance  of  squamous  epithelial  cells, 
showing  that  the  erosions  have  begun  to  cicatrize  and 
have  become  covered  with  newly  formed  epithelium. 
Clumps  of  gonococci  are  also  present,  adhering  to  the 
epithelium.  The  pus  cells  have  diminished  in  numbers 
and  a  smaller  number  of  them  contain  gonococci.  As 
the  disease  continues  to  improve,  pus  cells  and  gono- 
cocci disappear,  and  finally  the  discharge  from  the 
meatus  is  found  to  be  composed  only  of  squamous 
epithelium,  mucus,  and  an  occasional  pus  cell,  without 
gfonococci 


TREATMENT     OF     GONORRHEA  81 

PROGNOSIS 

The  virulence  of  the  gonococcus  differs  in  different 
cases.  It  is  often  noted  that  when  a  person  has  chronic 
gonorrhea  for  months  or  years,  the  gonococci,  when 
transplanted  into  the  tissues  of  another  person,  are  not 
capable  of  producing  such  virulent  inflammatory  symp- 
toms as  when  taken  from  a  fresh  case.  This  atten- 
uated virulence  explains  the  fact  that  in  such  cases  the 
period  of  incubation  is  comparatively  long  and  the 
purulent  discharge  scanty,  while  the  cases  often 
become  chronic  and  result  in  prostatitis  and  stricture. 

Another  factor  which  influences  the  prognosis  in 
gonorrhea  is  the  state  of  the  patient's  general  health. 
Gonorrhea  acquired  by  persons  affected  with  phthisis, 
or  who  are  debilitated  from  any  cause,  is  apt  to  run 
a  subacute,  but  exceedingly  protracted  course.  The 
other  causes  which  retard  recovery  may  be  grouped  as 
follows:  (a)  complications,  posterior  urethritis,  pros- 
tatitis, etc.;  (b)  reinfection  from  a  urethral  gland. 
seminal  vesicle,  prostate,  etc.;  (c)  lack  of  rest; 
(d)  alcoholic  indulgence;  (e)  too  vigorous  treatment, 
especially  injections  which  are  too  strong  or  too  fre- 
quently repeated;  (/)  coitus. 


82  THE     VENEREAL     DISEASES 

ACUTE     GONORRHEA 

In  order  to  aid  the  natural  process  of  repair,  the 
first  essential  is  rest.  No  other  measure  contributes 
so  much  to  a  prompt  and  uncomplicated  recovery  as 
rest  in  bed  during  the  acute  stage  of  gonorrhea.  The 
patient  should,  if  possible,  be  put  to  bed  and  kept  there 
during  the  ascending  stage  of  from  one  to  two  weeks, 
or  until  the  discharge  becomes  mucopurulent  and  the 
burning  on  urination  has  disappeared. 

In  order  to  keep  the  urine  bland  and  unirritating 
and  to  promote  frequent  urination,  so  as  to  clear  the 
urethra  from  the  products  of  inflammation  and  to 
expel  free  organisms  that  may  reinoculate  new  areas, 
the  patient  in  bed  should  drink  one  glass  of  water 
every  hour.  The  diet  should  be  bland  and  of  a  low 
nitrogen  content ;  highly  seasoned  and  rich  foods 
should  be  strictly  excluded ;  cereals,  fruit  juices,  toast 
and  cream  with  a  moderate  amount  of  milk  should 
make  the  bulk  of  the  meals. 

Alkalis  and  alkaline  mineral  waters  should  not  be 
prescribed,  because  of  their  effect  on  the  reaction  of 
the  urine.  An  acid  reaction  of  the  urine  is  the  best 
safeguard  against  a  cystitis  from  bacteria  that  find 
their  way  into  the  bladder.  The  acidity  of  the  urine 
will  be  reduced  sufficiently  by  the   free  use  of  milk 


TREATMENT  OF  GONORRHEA        83 

and  the  abstinence  from  meat.  The  bowels  should  be 
kept  open  with  aperients,  and  during  the  very  acute 
stage  a  saline  cathartic  should  be  administered  every 
other  morning. 

Dressings  for  the  purpose  of  catching  the  urethral 
discharge  to  keep  it  from  soiling  the  clothing  always 
should    be    worn.      Several    varieties    may    be    used: 
(a)    for  patients   with   a   long   foreskin,   the   familiar 
gauze  butterfly;   (b)    for  patients  unable  to  hold  the 
butterfly,    a    4-inch    gauze-bandage-bag    with    a    little 
E^auze  in  the  bottom,  made  fresh  daily  or  oftener,  or 
0)   a  loose  bag,  made  by  cutting  oft  the   foot  of  a 
stocking,  into  the  bottom  of  which  gauze  can  be  placed 
:o  catch  the  pus.     The  bags  are  to  be  suspended  from 
i  waist  band.     The  loose  bags  permit  and  encourage 
i  free  flow  of  pus  from  the  urethra,  while  they  prevent 
•etention.     Constriction    of    the    penis    by    dressings 
vrapped    around    it    should    carefully   be    avoided    so 
is  to   insure  no   interference   with   the   return   circu- 
ation.     A  suspensory  bandage  should  be  worn  when 
he  patient  is  allowed  to  get  up,  in  order  to  relieve  the 
ensation  of  dragging  on  the  spermatic  cord  and  to 
essen  perhaps  the  danger  of  epididymitis. 

Oil  of  sandalwood  is  soothing  and  curative  to  the 
nucous  membrane;  it  may  be  given  during  the  acute 


84  THE     VENEREAL     DISEASES 

stages,  but  will  have  little  effect  owing  to  dilution 
from  the  drinking  of  large  quantities  of  water.  San- 
dalwood oil  should  be  administered  in  capsules  in 
doses  of  from  0.5  to  1  c.c.  (8  to  15  minims)  three 
times  a  day  after  food.  It  sometimes  disagrees  with 
the  digestion,  or  it  may  cause  an  intense  pain  in  the 
back;  when  such  symptoms  occur,  it  should  be  dis- 
continued. No  copaiba  nor  cubebs  should  be  given  in 
acute  gonorrhea ;  they  are  serviceable  only  in  the 
declining  stages. 

SEVERE     ACUTE     URETHRITIS 

In  very  severe  urethritis  with  intense  reaction,  pro- 
fuse discharge,  and  great  swelling  and  edema,  it  is 
good  judgment  to  wait  for  some  subsidence  of  the 
symptoms  before  beginning  injections.  In  the  mean- 
time the  parts  should  be  kept  clean;  the  penis  held  ir. 
hot  water  for  fifteen  minutes  at  a  time  every  few 
hours,  and  hot  sitz  baths  given  every  three  or  foui 
hours  to  relieve  distress.  If  sitz  baths  are  unobtain- 
able, hot  fomentations  may  be  substituted.  If  pain  of 
urination  is  very  distressing,  it  may  be  relieved  by  ar 
injection,  five  minutes  before  urination,  of  1  c.c.  of  1 
per  cent,  solution  of  cocain  hydrochlorate  or  procainl 
Sandalwood  oil  diminishes  the  pain  on  urination  it 


TREATMENT  OF  GONORRHEA        85 

most  cases,  so  that  the  use  of  a  local  anesthetic  is  not 
often  necessary. 

Local  Treatment.— In  the  ascending  stage  of  acute 
urethritis  and  in  other  acute  cases,  which  do  not  reach 
the  intensity  suggested  in  the  preceding  paragraphs, 
local  treatment  by  injection  may  begin  at  once. 

In  selecting  the  drug  used  for  injection,  it  is  nec- 
essary to  bear  in  mind  the  indications  for  its  use, 
Ihich  may  be  thus  formulated: 

1.  To  destroy  the  gonococci  in  all  foci  within  reach 
is  early  and  completely  as  possible. 

2.  In  doing  so,  to  avoid  irritation  of  the  mucous 
nembranes,  any  exacerbation  of  the  existing  inflam- 
nation  and  everything  that  has  a  caustic  action  on  the 
issues,  and  all  unnecessary  pain. 

These  indications  are  very  well  met  by  the  silver 
>rotein  compounds  of  the  argyrol  and  protargol  type, 
rhe  syringe  should  be  all  glass,  of  5  c.c.  capacity, 
vith  a  smooth  acorn  tip.  For  injection,  fresh  solu- 
ions  in  water  of  the  following  strengths  are  used: 
-rgyrol,  from  3  to  5  per  cent.;  protargol,  from 
'.25  to  1  per  cent.  Before  injecting,  the  urine 
hould  be  passed  so  as  to  wash  out  the  pus  accumulated 
I  the  urethral  canal.  In  making  injections  the 
■  of  the  syringe  should  be  firmly  pressed  into  the 


86  THE     VENEREAL     DISEASES 

meatus,  and  the  penis  should  be  held  under  moderate 
tension.  Tire  solution  should  be  injected  with  the 
utmost  gentleness.  It  should  be  held  in  the  urethra  for 
at  least  five  minutes.  If  injections  produce  distress, 
their  strength  should  be  reduced.  Injections  should  not 
be  given  frequently  enough  nor  sufficiently  concen- 
trated to  cause  any  irritation  of  the  mucous  membrane ; 
an  injection  which  is  too  often  repeated  or  is  too  con- 
centrated prolongs  the  course  of  the  case.  In  practice 
it  is  found  that  once  in  two  hours  is  sufficiently  often 
to  destroy  the  gonococci  without  damaging  the  inflamed 
mucous  membrane,  provided  the  injection  is  carefully 
given  and  the  solution  is  not  too  strong. 

SUBACUTE     ANTERIOR     URETHRITIS 

After  from  ten  days  to  three  weeks  in  those  cases 
that  run  a  favorable  course  under  the  treatment  with 
silver  proteinates,  the  acute  symptoms  disappear.  The 
discharge  becomes  watery  and  scant;  microscopic 
examination  reveals  many  newly  formed  desquamated^ 
epithelial  cells  and  few  or  no  gonococci;  the  urine  in; 
the  first  glass  becomes  clear  or  slightly  turbid,  although; 
it  contains  many  long  mucous  filaments.  If  treatment 
is  now  discontinued,  relapse  with  extensive  reinfec- 
tion is  certain  to  occur  in  from  two  to  three  weeka 


TREATMENT     OF     GONORRHEA 


87 


from  the  few  gonococci  left  in  the  tissues.    When  the 
gonorrhea  has  reached  this  subacute  stage,  the  task 
remains  of  curing  the  existing  postgonorrheal  lesions, 
which  consist    of    a    catarrhal    inflammation    of    the 
mucous  membrane,  erosions,  periglandular  infiltrations, 
and  infiltrations  of  the  submucous  tissues.     Since  the 
silver  proteinates  only  destroy  the  gonococci  and  have 
little  effect  on  the  inflammatory  processes,  it  is  neces- 
sary at  this  time  to  treat  the  existing  catarrh  of  the 
mucous  membrane  with  astringent  remedies.     At  this 
ooint  in  the  progress  of  the  disease  it  is  highly  desir- 
ible  to  substitute  copious  irrigations  of  the  urethra 
ior  the  hand  injections. 

Irrigations^- -The  solution  best  adapted  for  the 
louble  purpose  of  destroying  the  few  remaining  gono- 
cocci and  of  acting  as  an  astringent  to  cure  the  super- 
icial  postgonorrheal  lesions  of  the  mucous  membrane 
5  silver  nitrate  in  strengths  of  from  1 :  3,000  to  1 :  5,000 
»f  distilled  water.  Irrigation  with  silver  nitrate  solu- 
ion  acts  particularly  well  in  the  presence  of  a  clear 
irine  containing  shreds  of  pus  or  mucous.  It  may  be 
ised  every  day  or  every  other  day.  Potassium  per- 
manganate in  water  solution  of  the  strengths  of  from 
:  3,000  to  1 :  5,000  is  also  useful  for  irrigations.  It 
5  especially  called  for  when  there  is  a  free  purulent 
ischarge     containing    no     organisms     and     may     be 


88  THE     VENEREAL     DISEASES 

repeated  three  or  four  times  daily,  if  it  does  not  pro- 
duce irritation.  A  purulent  discharge  that  arises 
from  the  presence  of  a  nongonococcic  bacterial 
urethritis  yields  to  daily  irrigation  with  mercuric 
oxycyanid  in  solution  in  water  in  strengths  of  from 
1 :  3,000  to  1 :  5,000.  This  should  never  be  used  if  the 
patient  is  taking  iodid  or  iodin  in  any  form.  The  irri- 
gations should  be  given  at  temperatures  of  from  110 
to  115  F. — as  hot  as  can  comfortably  be  borne. 

Technic  of  Irrigations. — The  patient  should  sit  well 
forward  on  the  chair,  resting  his  shoulders  against 
its  back,  or  he  may  stand.  He  should  hold  a  small 
basin  to  catch  the  overflow  of  the  irrigation. 
The  irrigator  tip  is  pressed  against  the  meatus  and 
the  anterior  urethra  distended  with  fluid.  Then  by 
a  short  release'  of  pressure  of  the  tip  a  return  flow  is 
allowed.  This  is  repeated  until  thorough  irrigation  of 
the  anterior  urethra  has  been  obtained.  If  it  is  desired 
to  irrigate  the  posterior  urethra,  the  anterior  urethra 
should  first  be  washed  out.  Then  the  tip  should  be 
firmly  pressed  against  the  meatus  and  the  anterioii 
urethra  dilated  with  fluid.  The  patient  is  therj 
instructed  to  take  a  long  breath  and  to  try  to  urinate  j 
this  releases  the  cut-off  muscle  and  the  irrigating  fluid 
flows  into  the  bladder.     The  bladder  is  allowed  to  fill 


TREATMENT     OF     GONORRHEA  89 

with  fluid,  but  should  not  be  distended  bevond  the  point 
of  comfort  After  the  bladder  is  fifled,  the  patient 
empties  it  by  urination.  Should  difficulty  be  experi- 
enced m  irrigating  the  posterior  urethra  from  the 
meatus  a  soft  rubber  catheter  may  be  introduced 
through  the  cut-off  muscle  into  the  posterior  urethra 
and  the  bladder  filled  through  the  catheter.  The 
iat,e„t  then  urinates  after  the  catheter  is  removed 

Lnder  the  irrigation  treatment  the  urethral  discharge 
*ases,  and  the  shreds  disappear  from  the  urine,  but 
.efore  the  patient  is  declared  cured  the  condition  of 
he  prostate  and  vesicles  must  be  investigated  and  the 
urethra  must  be  found  to  be  free  from  stricture 
It  should  be  borne  in  mind  that  it  is  possible  to  treat 
gonorrhea  too  long,  and  to  cause  the  discharge  to 
ersist  by  the  simple  irritation  of  injections.    In  such 
jes    there  will  be  a  secretion  free  from  gonococci 
*ch  on  squeezing  will  appear  at  the  meatus  as  a 
MI,  transparent,  glycerin-like  drop,  and  which  will 
mse  sticking  together  of  the  meatus  in  the  morning 
i  cases  manifesting  this  condition,  it  is  advisable  to 
op  treatment  and  to  allow  the  irritation  to  =ubside 
1  consequence,  the  mucous  discharge  will  often  disap- 
|ar  spontaneously. 


90  THE     VENEREAL     DISEASES 

ACUTE     POSTERIOR     URETHRITIS 

Posterior  urethritis  develops  as  a  rule  after  acute 
anterior  urethritis  has  become  subacute,  that  is,  from 
the  second  to  fourth  week  of  infection,  or  later.  It 
occurs  in  about  half  of  the  cases  of  gonorrhea.  Its 
occurrence  is  usually  due  to  the  spontaneous  spread  of 
the  infection  from  the  anterior  urethra ;  but  not  infre- 
quently the  tendency  to  its  spread  is  increased  by  too 
vigorous  local  treatment,  particularly  by  injudicious 
instrumentation.  It  may  occur  as  a  very  severe  procesS! 
or  more  frequently  as  a  subacute  one.  In  addition  tc 
the  urethra,  it  is  likely  to  involve  the  prostate  and  the 
base  of  the  bladder,  and  frequently  it  spreads  to  the 
seminal  vesicles  and  the  epididymis. 

The  onset  of  posterior  urethritis  will  not  escape 
detection,  if  the  two-glass  test  is  done  daily  as  a  routin 
measure.  A  turbidity  of  both  glasses,  when  due  I 
pus  and  not  to  phosphates,  denotes  involvement  of  th. 
posterior  urethra.  With  this  will  occur  frequent,  pair 
ful  urination. 

Severe  posterior  urethritis  demands  complete  rest  ij 
bed  and  measures  directed  to  the  relief  of  the  distresj 
ing  symptoms.  All  local  treatment  of  the  urethij 
should  be  suspended.  The  nearer  the  diet  approach: 
to  a  liquid  or  milk  diet,  the  better.     Abundant  war 


TREATMENT  OF  GONORRHEA       9] 

should   be  taken,   but   diuretics   should  not  be   u*ed 

because  they  cause  the  too  frequent  evacuation  of  an 

already  overtaxed  bladder.     Saline  cathartics  should 

eg.ven  every  other  day  to  reduce  congestion  in  the 

IT  flVhS  rCHef  °f  teneSmUS  and  Pai".  hot  sitz 
aths  of  half  an  hour's  duration,  repeated  several  time 
i  day,  are  useful.   Alkalies,  which  favor  the  growth  of 
-actena  m  the  bladder  by  rendering  the  urine  alkaline 
>re  contra.nd.cated,   as  they  are   in   acute   urethri     ' 
>anda> wood  o.l  is  not  only  curative  but  soothing ta 

ot  Id te  ln  man-'  "^    ^  th£  S6Vere  —  »£*■ 

rinate       t  ?Tt  *°   '*"   ^^   and   d«-e   to 
nna^It,  best  to  g,e  it  in  these  cases  in  recta,  sup- 
As  a  rule,  the  acute  stage  of  posterior  urethritis  dis- 

rnild  Pnrt,y'  Md  the  CaS£S  P3SS  int0  ^  -n^oo 
rn.ldposter.or  urethritis,  and  then  should  be  treated 

Treatment  of  MM  Posterior   Urethritis. -^   sub- 
u  e  po.ter.or  urethritis,  treatment  is  given  on  prin- 

fcrir  s-o!°t ose  appHcabie  to  subacute  a^ 

■tabs.    Solutions  are  applied  to  the  surface,  either 

ii;rrofsmaiiquantife°fM~^ 

«e  solutions7  lmgat,°nS  °f  C°PI'°US  ^^  °f 


92 


THE     VENEREAL     DISEASES 


In  the  first  method,  a  small  soft  rubber  catheter  is 
introduced  just  beyond  the  cut-off  muscle,  and  by 
means  of  a  small  urethral  syringe  about  ten  drops  of 
1 :  500  to  1 :  100  solution  of  silver  nitrate  are  intro- 
duced into  the  posterior  urethra.  This  is  to  be 
repeated  at  intervals  of  one  or  two  days  according  to 
the  tolerance  of  the  case.  In  order  to  prevent  immedi- 
ate precipitation  of  the  silver  by  the  urine,  the  injec- 
tion should  be  made  with  the  bladder  empty. 

Urethrovesical  irrigations  by  the  gravity  method 
are  particularly  applicable  to  the  treatment  of  posterior 
urethritis.  They  are  given  through  a  gravity  irrigator 
elevated  five  to  six  feet  above  the  penis,  according  to 
the  technic  already  described  for  irrigation.  For  pos- 
terior irrigations,  protargol  or  similar  silver  protein 
preparation  in  the  strength  of  from  1 :  1,000  to  1 :  2d0, 
or  silver  nitrate  from  1 :  10,000  to  1 : 4,000  are  used. 
Less  effective,  but  still  useful  in  some  cases,  is  potas- 
sium permanganate,  1 :  3,000. 

As  a  rule,  posterior  urethritis  extends  to  the  prostat< 
and  seminal  vesicles,  and  persistence  depends  on  rein 
fection  from  these  structures.  In  every  case  the* 
structures  should  be  examined  and,  if  necessary 
treated. 


COMPLICATIONS    OF    ACUTE    GONORRHEA 


FOLLICULITIS 

Folliculitis  consists  in  suppuration  of  one  of  the 
urethral  follicles  with  retention  of  the  pus,  forming  a 
small  abscess.  This,  if  left  to  itself,  opens  spontane- 
ously either  into  the  urethra  or  through  the  skin.  If 
it  ruptures  through  the  skin  it  is  likely  to  leave  a 
fistula  in  the  urethra  which  is  very  persistent.  The 
treatment  consists  in  opening  the  abscess  freely  as 
soon  as  fluctuation  is  noticed,  evacuating  the  pus, 
and  allowing  it  to  heal  by  granulation.  It  should  be 
opened  through  a  urethroscope  from  within  the 
urethra,  when  this  is  practicable.  If  incision  is  done 
promptly,  the  occurrence  of  a  persistent  urethral  fistula 
is  prevented. 

CHORDEE 

The  patient  subject  to  chordee  should  empty  his 
bladder  just  before  going  to  bed  ;  should  sleep  in  a  cool 
place,  lightly  covered;  and,  to  avoid  sleeping  on  his 
back,  should  tie  a  towel  around  his  waist  with  a  knot 
at  the  back.  Before  going  to  bed  the  penis  should 
be    given    a    prolonged    immersion    in    hot    water. 


94  THE     VENEREAL     DISEASES 

When  the  patient  wakes  with  chordee,  he  should  get 
out  of  bed  and  immerse  penis  and  testicles  in  cold  or 
hot  water,  and  before  going  back  to  bed  should  empty 
the  bladder.  He  should  be  warned  of  the  danger  oi 
"breaking"  a  chordee.  In  severe  cases  sedatives  are 
necessary:  potassium  bromid,  2.0  gm.,  or  camphor 
monobromate  0.3  gm.,  in  the  afternoon  and  before 
going  to  bed.  are  useful :  in  extreme  cases  a  morphin 
rectal  suppository  ma}7  be  necessary. 

EPIDIDYMITIS 

Immediately  on  the  development  of  epididymitis 
all  injections  or  instrumentation  of  the  urethra  must  be 
stopped,  the  patient  be  confined  to  bed.  and  put  on  a 
light  diet.  The  testicles  should  be  elevated  by  a  band- 
age going  under  them  and  over  the  thighs,  and  hot 
applications  should  be  made.  Hot  sitz  baths  for  half  an 
hour  three  times  daily  are  soothing  and  hasten  recov- 
ery. If  the  symptoms  are  severe,  epididymotomy 
may  be  performed.  This  immediately  relieves  pain 
and  hastens  recovery. 

In  a  few  days  the  acute  stage  passes.  The  urethral 
discharge  is  then  likely  to  recur,  but  local  treatment 
of  the  urethra  must  be  resumed  only  after  a  consider- 
able period  of  rest  and  with  the  greatest  caution.  A 
suspensory  bandage  should  be  worn  until  the  patient 


COMPLICATIONS     OF     GONORRHEA  95 

is  entirely  well.  There  is  in  many  of  these  cases  a 
chronic  inflammatory  exudate  in  the  epididymis,  which 
in  time  often  disappears.  Massage  of  it  may  hasten 
its  absorption. 

ACUTE     PROSTATITIS 

In  acute  prostatitis  the  indications  are  (1)  to  les- 
sen the  severity  of  the  posterior  urethritis:  (2)  to 
prevent  suppuration  of  the  prostate  :  I  3  I  if  pus  forms. 
to  evacuate  it  promptly  by  incision. 

The  patient  should  be  put  to  bed.  sandalwood  oil 
administered,  and,  if  necessary,  the  pain  and  tenesmus 
controlled  by  opium  suppositories.  Locally  either  ice- 
bags  or  hot  poultices  are  applied  to  the  perineum,  a 
safe  guide  for  the  choice  between  hot  and  cold  apr.:- 
cations  being  the  amount  of  comfort  which  is  given  to 
the  patient.  Hot  sitz-baths  of  from  one-half  hour  to 
an  hour's  duration  two  or  three  times  daily  are  alwavs 
indicated.  Irrigation  of  the  rectum  with  hot  water 
for  half  an  hour  at  a  time  may  be  used  instead.  A 
rectal  prostatic  irrigator  or  in  its  absence  a  return- 
flow  catheter  is  introduced  into  the  rectum,  and  a  con- 
tinuous flow  of  water  as  hot  as  can  be  borne,  is 
passed  through  it. 

If  retention  of  urine  should  occur,  it  may  be  neces- 
sary to  introduce  a  catheter,  but  this  should  be  done 


96  THE     VENEREAL     DISEASES 

only  when  absolutely  necessary.  Before  catheterizing, 
the  urethra  should  be  well  irrigated  to  free  it  from 
pus.  One  c.c.  of  2  per  cent,  cocain  solution  may  be 
injected  into  the  urethra  to  relieve  pain  and  facilitate 
catheterization. 

Prostatic  Abscess.  —  When  a  very  limited  area  of 
suppuration  of  the  prostate  is  present,  involving  per- 
haps two  or  three  of  the  prostatic  tubules,  the  tem- 
perature is  only  slightly  elevated,  and  the  local  symp- 
toms are  not  marked.  After  two  or  three  days  the 
temperature  becomes  normal  and  the  tenesmus  and 
frequent  urination  disappear.  In  such  cases  an  inci- 
sion into  the  prostate  is  not  required,  for  the  minute 
abscess  generally  ruptures  into  the  urethra  and  the 
sinus  fills  in  by  granulation. 

If,  on  the  contrary,  the  symptoms  do  not  improve 
within  the  first  week,  but  the  fever  continues  and  chills 
occur,  the  local  symptoms  grow  worse,  and  rectal 
examination  shows  an  increase  in  the  size  of  the 
inflamed  prostate,  it  is  evidence  that  an  abscess  is 
forming.  These  symptoms  constitute  an  urgent  indica- 
tion to  evacuate  the  pus ;  for  if  the  pus  is  allowed  to 
break  through  the  capsule  of  the  prostate,  it  will  bur- 
row through  the  tissues  and  may  cause  urinary  infiltra- 
tion and  pyemia,  or,  at  least,  a  fistula  which  will  not 


COMPLICATIONS     OF     GONORRHEA  97 

heal  without  operation.  In  these  cases  immediate  sur- 
gical measures  are  indicated.  Two  operations  may  be 
used  to  evacuate  the  pus. 

1.  The  prostate  may  be  exposed  by  a  transverse 
incision  in  the  perineum,  and  the  collection  of  pus 
evacuated  without  opening  the  urethra. 

2.  An  incision  may  be  made  in  the  perineal  urethra, 
the  mucous  membrane  of  the  prostatic  urethra  broken 
through  with  the  finger,  and  the  pus  collection  evacu- 
ated through  the  opening  thus  made. 

ACUTE     SEMINAL     VESICULITIS 

The  general  treatment  of  acute  vesiculitis  is  the 
same  as  that  for  acute  prostatitis,  with  which  it  is 
usually  associated.  Injections  into  the  anterior  ure- 
thra, of  course,  are  contraindicated ;  but  above  all 
things,  any  attempt  at  massaging  or  stripping  the 
vesicles  should  be  avoided. 

gonorrheal   ophthalmia 

Every  case  of  acute  conjunctivitis  in  a  gonor- 
rheal PATIENT  IS  A  CONDITION  REQUIRING  EXPERT 
ATTENTION,  AND  SHOULD  BE  IMMEDIATELY  REFERRED 
TO    AN    OPHTHALMOLOGIST. 


CHRONIC     GONORRHEA 


Gonorrhea  may  be  said  to  be  chronic  when  it  has 
lasted  over  six  weeks.     Chronic  gonorrhea  is  always 
dependent  on  distinct  pathologic  changes  in  the  tissues, 
the  nature  of  which  must  be  understood  in  order  to 
apply  correct  treatment.     For  instance,  it  is  useless  to 
attempt  to  cure  a  urethral  discharge  from  a  chronically 
inflamed   area  behind   a   stricture,   by   massaging  the 
prostate.     It  is  equally  futile  to  endeavor  to  relieve  a 
urethritis  depending  on  a  chronic  prostatitis,  by  dilata- 
tion and  irrigation  of  the  urethra.     In  most  cases  of 
chronic  gonorrhea,  especially  those  of  long  standing, 
the  prostate,  vesicles  and  urethral  canal  participate  in 
the  pathologic  changes,  and  it  is  necessary  to  carry  out 
the  examination  in  a  systematic  manner  in  order  not 
to  overlook  the  various  lesions.    The  following  scheme 
for  this  examination  is  found  to  be  practical : 

1.  History  taken. 

2.  Inspection  of  external  genitals. 

3.  Urethral  smears  taken  for  microscopic  examination. 

4.  Urine  passed :  two-glass  test. 

5.  Prostate  and  vesicles  palpated  by  rectum,  and  expressec 
material  collected  on  a  glass  slide  for  gross  and  micro; 
scopic  examination. 


CHRONIC     GONORRHEA  99 

6.  Bougie  a  boule  examination  of  urethra  for  stricture,  and 
meatotomy  if  necessary.  For  this  purpose  a  bougie  with  a 
26  or  28  F.  tip  should  be  used. 

7.  Endoscopic  examination  of  anterior  urethra ;  also  of 
posterior  urethra  in  special  cases. 

All  findings  should  be  recorded  as  the  examination  is  made. 
CHRONIC     ANTERIOR     URETHRITIS 

The  important  pathologic  change  in  the  urethral 
tissues  in  gonorrhea  is  an  infiltration  of  small  round 
cells  underneath  the  mucous  membrane,  surrounding 
and  embedding  Morgagni's  crypts  and  Littre's  glands. 
If  the  infiltration  is  superficial  it  is  absorbed,  but  if  it 
is  extensive,  the  round  cells  become  converted  into 
connective  tissue,  forming  stricture.  The  mucous  mem- 
brane lining  the  urethra  is  destroyed  in  spots,  leaving 
erosions,  and  these  erosions  as  a  result  of  inflammatory 
proliferation  become  converted  into  areas  of  granula- 
tions. In  other  cases  the  mucous  membrane  is  not 
eroded  and  no  granular  patches  are  present ;  instead  of 
loss  of  substance  there  is  swelling,  congestion  and 
edema  of  the  mucous  membrane,  which  is  the  seat  of 
chronic  inflammation.  The  infiltration  around  the 
crypts  of  Morgagni  keep  their  mouths  open,  which 
condition  permits  the  cavities  to  become  incubating 
places  for  colonies  of  gonococci,  from  which  reinfec- 
tions repeatedly  take  place.    The  above  described  con- 


100  THE     VENEREAL     DISEASES 

ditions  occasion  a  continuous  gleety  discharge,  which 
will  remain  until  they  are  removed. 

Treatment. — Based  on  the  pathologic  changes  in  the 
tissues,  the  indications  for  treatment  are : 

(a)  To  rid  the  tissues  of  gonococci. 

(b)  To  cure  the  catarrhal  inflammation  in  the 
mucous  membrane  and  promote  the  formation  of 
squamous  epithelium  to  cover  the  erosions. 

(c)  To  cause  absorption  of  the  submucous  infil- 
tration. 

(d)  To  restore  to  normal  the  intraglandular  and 
periglandular  inflamed  and  infiltrated  tissues. 

These  indications  can  be  met  by  irrigations  with 
antiseptic  and  astringent  solutions  and  by  dilatations  of 
the  urethra  with  sounds  and  soft  bougies. 

When  general  catarrh  of  the  mucous  membrane  is 
present  and  turbidity  of  Glass  1  exists,  free  irrigation 
of  the  urethra  and  bladder  by  the  gravity  method, 
daily  or  every  second  day,  using  silver  nitrate  or  potas- 
sium permanganate,  soon  clears  up  the  diffuse  inflam- 
mation in  the  mucous  membrane,  until  the  process  is 
no  longer  general,  but  is  reduced  to  isolated  spots. 
This  condition  is  denoted  by  Glass  1  being  no  longer 
turbid ;  it  does,  however,  still  contain  the  shreds  derived 
from    isolated    erosions    which    are    not    covered    by 


CHRONIC     GONORRHEA  101 

epithelial  cells  and  are  still  secreting  pus,  or  from  the 
prostatic  ducts  and  Morgagni's  crypts.  Comma-shaped 
shreds  which  are  often  present  are  formed  by  the 
secretion  from  the  open  mouths  of  the  prostate  ducts 
and  Morgagni's  crypts.  Gonorrheal  shreds  floating  in 
clear  urine  continue  until  the  submucous  infiltrations 
resolve  and  the  pathologic  secretion  of  the  prostate 
and  crypts  disappears. 

In  order  to  promote  the  absorption  of  the  submucous 
infiltration  it  is  necessary  to  pass  steel  sounds  large 
enough  to  distend  the  urethra  fully  and  put  the  ring 
of  infiltration  on  the  stretch.  Meatotomy  may  be  nec- 
essary in  order  to  pass  sounds  of  sufficient  size. 

The  therapeutic  effects  of  the  sound  can  be  materi- 
ally increased  by  massaging  the  urethra  over  it  with 
the  fingers.  The  contents  of  Morgagni's  crypts  can 
in  this  way  be  expressed,  and  more  favorable  influence 
is  exerted  on  the  ring  of  infiltration  in  the  submucous 
tissues. 

Sounds  may  be  passed  too  frequently.  In  cases  of 
soft  and  recent  infiltration,  the  intervals  should  be 
from  four  to  seven  days,  always  waiting  until  the 
reaction  following  has  subsided.  In  cases  of  hard, 
organized  infiltration  the  intervals  should  be  a  week. 
If  the  urethra  is  acutely  inflamed  and  freely  secret- 


102  THE     VENEREAL     DISEASES 

ing  pus,  instrumentation  is,  of  course,  out  of  the  ques- 
tion. Dilatations  should  not  be  started  until  the  urine 
is  clear  and  contains  only  shreds. 

It  makes  no  difference,  as  far  as  treatment  is  con- 
cerned, whether  the  submucous  round  cell  infiltration 
is  soft  and  recent  or  whether  it  has  been  transformed 
into  scar  tissue ;  the  indications  in  either  case  are  to 
promote  its  absorption  by  dilatation  and  pressure. 
Cases  in  which  a  considerable  surface  of  mucous  mem- 
brane is  involved  are  unsuitable  for  dilatation  until 
the  catarrh  has  been  checked  by  irrigations,  and  the 
superficial  process  has  been  localized  in  a  few  spots 
in  the  urethra,  as  denoted  by  shreds  floating  in  clear 
urine. 

GLANDULAR     URETHRITIS 

Many  intractable  cases  of  gonorrhea  lasting  for 
years  in  spite  of  constant  treatment  are  caused  by  a 
chronic  inflammation  of  Morgagni's  crypts.  Such 
cases  show  few  symptoms,  the  morning  drop  at 
the  meatus  being  the  most  constant.  But  they 
are  characterized  by  exacerbations  of  the  discharge 
after  slight  provocation,  with  a  free  discharge  of  pus 
containing  gonococci,  which  leads  the  patient  to  believe 
that  he  has  acquired  a  fresh  infection.  Urethroscopic 
examination  shows  the  mouths  of  a  few  of  the  crypts 


CHRONIC     GONORRHEA  103 

to  be  open  and  pouting,  with  red  and  slightly  elevated 
edges.  In  other  cases  the  mouths  of  the  crypts  are 
occluded  by  a  growth  of  epithelium.  When  the  crypts 
are  affected  the  gonococci  may  remain  in  them  for 
years  and  the  case  remain  infectious. 

These  cases  should  be  treated  by  dilatations  with 
full  sized  sounds  followed  by  irrigations.  When  the 
mouths  of  the  glands  are  occluded  by  the  growth  of 
epithelium,  dilatation  of  the  urethra  opens  them  and 
forces  out  the  purulent  secretion.  The  irrigating  fluid 
enters  the  cavities  and  acts  on  the  chronic  inflam- 
matory processes  within  the  glands.  In  that  form  of 
inflammation  in  which  the  mouths  of  the  glands  are 
held  open  and  the  entire  crypt  is  stiffened  and  inelastic 
from  the  periglandular  infiltration,  dilatations  cause 
the  absorption  of  the  infiltrate  around  the  glands  and 
promote  a  return  to  normal  condition. 

When,  after  sufficient  treatment  by  dilatations  and 
irrigations,  it  is  found  by  urethroscopic  examination 
that  a  few  glands  still  remain  chronically  inflamed  and 
suppurating,  and  are  thus  foci  of  infection,  these 
should  be  destroyed.  This  can  be  accomplished 
by  bringing  them  into  view  with  the  urethroscope,  and 
introducing  a  galvanocaustic  needle.  The  cauteriza- 
tion must  be  very  superficial  and  rapid ;  otherwise 
there  will  be  danger  of  stricture  formation.    Not  more 


104  THE     VENEREAL     DISEASES 

than  three  or  four  crypts  may  be  destroyed  at  a  sitting. 
It  is  possible  by  destroying  the  glands  harboring  the 
gonococci  to  cure  in  this  way  a  chronic  gonorrhea  of 
years'  standing  which  has  resisted  all  the  other  usual 
forms  of  treatment. 


CHRONIC     POSTERIOR     URETHRITIS 


Acute  posterior  urethritis  may  recover  without 
becoming  chronic ;  more  frequently  it  passes  into  a 
chronic  stage  analogous  in  its  pathologic  changes  to 
those  of  chronic  anterior  urethritis.  In  chronic  pos- 
terior urethritis  due  to  gonorrhea,  the  prostate  and 
seminal  vesicles  are  usually  involved.  Acute  posterior 
urethritis  is  invariably  caused  by  the  gonococcus,  but 
chronic  posterior  urethritis  is  produced  by  other 
causes,  among  which  are  excessive  sexual  intercourse, 
masturbation,  or  perineal  traumatism,  as  from  horse- 
back riding. 

DIAGNOSIS 

A  history  of  uncured  gonorrhea  or  sexual  abuse, 
especially  when  accompanied  by  the  symptoms  of 
sexual  neurasthenia,  prostatorrhea,  and  urinary  and 
sexual  disturbances,  point  to  chronic  posterior  urethri- 
tis. Examination  is  necessary  to  confirm  the  diagnosis. 
The  two-glass  urine  test  is  useful  only  in  the  event 
of  a  considerable  amount  of  pus  formation,  in  which 
cases  Glasses  1  and  2  are  turbid,  and -contain  small 
shreds  like  commas  from  the  mouths  of  the  prostatic 


106  THE     VENEREAL     DISEASES 

ducts,  the  so-called  "Furbinger's"  hooks.  When  the 
secretion  of  the  posterior  urethra  is  scanty  the  diag- 
nosis should  be  confirmed  by  examination  with  the 
posterior  urethroscope.  The  posterior  urethra  is  found 
to  be  purple,  bleeding  freely,  and  may  be  the  seat  of 
granulations.  The  colliculus  is  swollen  and  edema- 
tous, filling  the  end  of  the  tube,  and  bright  red  or 
bluish,  and  small  polypi  are  often  noted  growing  on  its 
surface.  In  time  the  submucous  infiltration  becomes 
converted  into  connective  tissue,  and  the  colliculus  is 
flat,  irregular  and  grayish  white. 

TREATMENT 

In  the  presence  of  free  pus  formation,  urethrovesical 
irrigations  by  the  gravity  method  with  a  solution  of 
silver  nitrate  from  1 :  10,000  to  1 : 4,000  or  potassium 
permanganate,  1 :  3,000,  is  the  best  method  of  rapidly 
reducing  the  purulent  discharge.  After  the  urethra 
becomes  clear,  the  prostate  and  vesicles  should  be 
examined,  and  if  found  to  be  diseased  must  be  mas- 
saged in  connection  with  the  irrigation.  When  the 
urethroscope  shows  the  infiltrated  changes  localized  to 
the  colliculus,  direct  applications  of  from  10  to  20 
per  cent,  silver  nitrate  solution  should  be  made  once 
a  week  through  the  endoscope.     Granulations  in  the 


CHRONIC     POSTERIOR     URETHRITIS  107 

posterior  urethra  should  be  treated  by  cauterizing  with 
strong  silver  nitrate  solution.  Small  polypi,  or  granu- 
lations on  the  colliculus  may  be  removed  by  scissors, 
forceps  or  a  galvanocaustic  point.  If  the  utricle  is 
infected  it  should  be  injected  with  silver  nitrate  solu- 
tion with  a  small  syringe. 

Chronic  Prostatitis. — In  almost  every  case  of  chronic 
gonorrheal  urethritis  the  prostate  is  involved.  Chronic 
prostatitis  usually  originates  in  an  attack  of  acute 
prostatitis,  but  it  may  result  from  a  slow,  insidious 
extension  through  the  prostatic  ducts  of  an  infection 
from  the  posterior  urethra.  Aside  from  its  frequency, 
chronic  prostatitis  is  perhaps  the  most  important  com- 
plication of  gonorrhea,  for  the  reason  that  the  gono- 
coccus,  with  all  its  infectious  qualities  unimpaired,  may 
be  retained  for  years  in  the  diseased  tubular  glands  of 
the  prostate  without  its  presence  being  suspected. 
Probably  most  of  the  cases  in  which  wives  are  infected 
with  gonorrhea  by  their  husbands  come  from  uncured 
prostatitis.  Chronic  prostatitis  is  also  important  on 
account  of  the  profound  disturbance  of  the  nervous 
system  and  the  impairment  of  the  sexual  function. 
which  it  occasionally  produces. 

The  first  indication  in  the  treatment  of  chronic 
prostatitis  is  to  improve  the  general  condition  of  the 


108  THE     VENEREAL     DISEASES 

patient  by  a  proper  regimen.  Constipation  is  generally 
a  prominent  symptom,  which  is  best  treated  with 
saline  cathartics,  because  they  have  some  effect  in 
relieving  pelvic  congestion.  All  sorts  of  erotic  excite 
ment  should  be  interdicted  on  account  of  their  effect 
in  inducing  congestion  of  the  prostate.  Coitus  should 
not  be  permitted,  both  because  of  its  ill  effect  on  the 
diseased  prostate  and  because  of  the  certainty  of 
spreading  the  infection. 

The  most  effective  local  measure  is  the  emptying  of 
the  prostatic  tubules  of  their  retained  and  thickened 
contents  by  rectal  massage  two  or  three  times 
weekly.  In  this  procedure  both  lobes  should  be 
massaged  from  above  downward  and  the  manipulation 
should  not  be  very  vigorous,  the  object  being  to  force 
out  the  prostatic  contents  by  moderate  pressure.  Mas- 
sage of  the  prostate  is  not  well  borne  by  all  patients ; 
and,  if  it  produces  irritating  symptoms,  it  should  not 
be  persisted  in.  In  order  to  lessen  the  danger  of 
epididymitis  from  prostatic  massage,  it  is  advisable  to 
irrigate  the  urethra  and  fill  the  bladder  before  mas- 
sage with  a  solution  of  silver  nitrate  from  1 :  10,000 
to  1 :  4,000  or  potassium  permanganate  1 :  3,000. 

Treatment  by  massage  and  irrigation  should  be 
persisted  in  for  from  six  to  eight  weeks,  or  until  a 


CHRONIC     POSTERIOR     URETHRITIS  109 

microscopic  examination  of  the  expressed  prostatic 
secretion  shows  only  a  small  number  of  pus  cells  in 
the  field.  Many  cases  will  be  found  to  improve  under 
massage  up  to  a  certain  point  and  then  remain  sta- 
tionary. In  such  instances  it  is  advisable  to  stop 
treatment  for  a  month.  If  after  this  intermission  the 
remaining  evidences  of  prostatitis  have  not  disap- 
peared, another  course  of  massage  may  be  given. 
Such  treatment  should  be  repeated  until  the  pus  cells 
in  the  expressed  prostatic  secretion  are  found  on  micro- 
scopic examination  to  be  only  from  four  to  six  in  a 
field,  and  lecithin  bodies  are  abundant. 

While  treating  chronic  prostatitis,  it  is  important  not 
to  overlook  the  chronic  posterior  urethritis  which 
nearly  always  accompanies  it.  This  should  be  treated 
by  irrigation,  dilatation,  and  other  measures,  as 
already  described. 

Chronic  Seminal  Vesiculitis.  —  Chronic  vesiculitis 
may  originate  from  an  acute  attack  of  vesiculitis 
which  does  not  undergo  resolution ;  but  as  a  rule  it 
develops  insidiously,  as  the  result  of  the  extension  of 
a  chronic  inflammatory  process  which  begins  in  the 
posterior  urethra  and  extends  through  the  ejaculatory 
duct.  The  ejaculatory  duct  is  never  occluded  by  the 
changes;  throughout  the  whole  course  of  the  disease 


110  THE     VENEREAL     DISEASES 

it  remains  patulous,  and  sterility  does  not  occur  from 
this  cause. 

Chronic  seminal  vesiculitis  presents  itself  in  two 
varieties : 

1.  Atonic  vesiculitis,  in  which  there  is  chiefly  an 
atony  of  the  muscular  fibers  composing  the  walls  of 
the  vesicle. 

2.  Inflammatory  vesiculitis,  in  which  the  walls  of  the 
vesicles  are  thickened  and  indurated  as  a  result  of 
inflammation,  which  may  be  simple,  gonorrheal,  or 
tuberculous  in  origin. 

Either  form  of  vesiculitis  may  exist  by  itself ;  but 
usually  there  is  a  combination  of  atony  and  inflam- 
mation of  the  vesicular  walls. 

Treatment. — The  treatment  consists  in  massaging 
and  expressing  the  contents  of  the  vesicles  twice  a 
week.  Massaging  empties  the  vesicles  of  their  inspis- 
sated contents,  without  forcing  the  muscular  fibers  to 
contract;  and,  by  the  relief  of  distention  and  the  rest 
thus  afforded  them,  the  muscles  recover  their  tone. 

Contraindications  to  massaging  are:  (a)  the  exist- 
ence of  acute  vesiculitis;  (b)  blood  in  the  expressed 
material,  or  (c)  excessive  tenderness.  With  these  con- 
ditions present,  there  is  always  danger  of  setting  up 
an  epididymitis. 


CHRONIC     POSTERIOR     URETHRITIS  111 

In  chronic  vesiculitis  the  posterior  urethra  should 
not  be  overlooked,  but  should  receive  treatment,  with 
irrigations  or  instillations  or  by  applications  made 
through  the  urethroscope  as  outlined  under  chronic 
posterior  urethritis.  It  is  desirable  not  to  apply  local 
treatment  to  the  posterior  urethra  and  massage  the 
vesicles  at  the  same  sitting,  but  rather  to  allow  a 
couple  of  days  to  intervene. 

The  duration  of  treatment  must  be  protracted,  for 
it  requires  from  two  to  twelve  months  to  effect  a  cure. 
In  obstinate  cases  characterized  by  marked  sexual 
neurasthenia  or  intractable  gonorrheal  rheumatism, 
free  incision  into  and  drainage  of  the  seminal  vesicles 
may  be  demanded.  This  is  a  procedure  requiring 
expert  skill. 

CURE 

Under  treatment,  as  outlined  above,  cure  can  be 
obtained  in  practically  all  cases  of  gonorrhea.  If, 
under  such  treatment,  symptoms  persist  beyond  a 
reasonable  time  in  chronic  cases,  it  is  an  evidence- 
that  some  focus  of  infection  persists  which  has  been 
overlooked;  and  these  cases  should  be  carefully  reex- 
amined by  an  expert  urologist.  It  may  not  be  possible 
to  cause  the  entire  cessation  of  mucopurulent  dis- 
charge from  the  meatus  or  the  disappearance  of  all 
shreds  from  the  urine,  while  treatment  is  continued ; 


112  THE     VENEREAL     DISEASES 

for  this  in  itself  may  produce  sufficient  irritation  to 
keep  up  a  degree  of  inflammation  of  the  urethral 
mucosa.  If  gonococci  are  absent,  it  is  proper,  in  esti- 
mating the  situation  in  a  case,  to  disregard  light  fila- 
ments in  the  urine  and  a  slight  mucoid  discharge  from 
the  meatus,  and  confidently  to  expect  that  these  will 
disappear  spontaneously  with  the  cessation  of  treat- 
ment. 

TEST     OF     CURE     OF     GONORRHEA 

The  man  should  take  vigorous  exercise  on  the  day 

before  the  one  on  which  the  examination  is  to  be  made. 

He  should  not  urinate  for  two  hours  before  the 
examination  is  made. 

Examination   should   show   the   following  findings : 

1.  He  should  have  no  uretheral  discharge. 

2.  If  a  drop  is  found,  it  must  be  free  from  gonococci. 

3.  In  the  two-glass  test,  both  Glass  1  and  Glass  2  must  be 
clear  and  free  from  pus  shreds.  Epithelial  shreds  free  from 
gonococci  may  be  disregarded. 

4.  The  secretion  obtained  by  massage  of  the  prostate  and 
seminal  vesicles  must  show  no  gonococci  and  few  leukocytes. 

5.  Examination  with  a  bougie  a  boule  should  demonstrate 
the  absence  of  stricture. 

GONORRHEAL     RHEUMATISM     AND     METASTATIC 
GONORRHEA 

Infections  of  Synovial  Membranes. — The  most  fre- 
quent metastasis  of  the  gonococcus  is  seen  in  the  infec- 


CHRONIC     POSTERIOR     URETHRITIS  113 

tion  of  the  synovial  membranes,  which  usually  develops 
in  the  third  week  of  the  disease,  after  involvement  of 
the  posterior  urethra.  Traumatism  may  be  a  predis- 
posing factor.  Gonorrheal  rheumatism  is  an  inflamma- 
tion of  one  or  more  joints  caused  by  the  deposit  of 
gonococci  carried  to  the  synovial  membranes  through 
the  blood  current.  Three  forms  may  be  distinguished : 
(1)  a  hydrarthrosis  usually  confined  to  a  single  joint 
(monarticular),  generally  the  knee;  (2)  an  arthritis 
resembling  ordinary  rheumatism,  as  it  begins  with 
fever  and  involves  several  joints,  and  (3)  an  inflam- 
mation of  the  synovial  sheaths  of  tendons  and  muscles 
and  the  bursae,  which  become  seats  of  chronic  inflam- 
matory changes — the  joints  may  be  involved  or  they 
may  escape.  The  course  of  all  these  forms  is  very 
slow. 

Should  gonorrheal  rheumatism  develop,  it  is  impor- 
tant promptly  to  begin  active  treatment;  for  it  is  a 
serious  complication,  and  if  not  treated  energetically 
at  first  it  becomes  chronic  find  very  difficult  to  cure. 
Pericarditis  and  endocarditis  may  arise ;  ulcerations  of 
the  valves  may  take  place,  and  vegetations  containing 
gonococci  may  form  on  them.  Early  advice  from  an 
expert  orthopedist  should  be  sought.  It  is  essential  to 
continue  to  treat  the  gonorrhea,  which  has  become 
chronic  and  which  frequently  has  involved  the  prostate 


114 


THE     VENEREAL     DISEASES 


and  the  seminal  vesicles.  The  presence  of  a  chronic 
vesiculitis  that  doe's  not  respond  to  treatment  by  mas- 
sage requires  a  seminal  vesiculotomy  with  drainage  in 
order  to  stop  further  absorption  of  the  toxin.  Gonor- 
rheal vaccines  are  useful  in  some  cases. 


SUMMARY     OF     MANAGEMENT     OF 
GONORRHEA 


A.  Keep  the  urethra  free   from  the  products   of  inflamma- 

tion in : 

1.  Acute  gonorrhea  by: 

(a)  Ingesting  so   large   quantities   of  water   as 

to  cause  frequent  urination. 

(b)  Immersing  the  penis  in  water  as  hot  as  can 

be  borne   for    from   five   to   ten   minutes 
three  times  a  day. 

2.  Chronic  gonorrhea  by: 

(a)  Emptying  the  prostate  and  the  seminal  ves- 

icles of  inflammatory  products  and  im- 
proving the  circulation  of  blood  in  these 
organs. 

(b)  Causing  the  absorption  of  submucous  infil- 

tration. 

(c)  Healing  erosions  of  the  mucous  membrane. 

B.  Apply    antiseptics    frequently    in    order    to    destroy    the 

organisms  in : 

1.  Acute  gonorrhea  by  : 

(a)  Injections,  hand,  mild,  at  frequent  intervals. 

(b)  Administration  of  selected  drugs  by  mouth. 

2.  Chronic  gonorrhea  by : 

(a)   Irrigations,  mild,  at  frequent  intervals. 
(&)  Administration  of  selected  drugs  by  mouth. 


116  THE     VENEREAL     DISEASES 

D.  Individualize  management  in : 

1.  Hospitals  by  having: 

(a)   Separate  toilets  for 

(1)  Gonorrheics. 

(2)  Syphilitics. 

(&)    Separate  wards  or  sections  of  a  ward  for: 

(1)  Gonorrheics. 

(2)  Syphilitics. 

(r)  Ward  equipment  marked  so  as  to  be  used 
only  by  patient  occupying  correspondingly 
numbered  bed. 

1.  Patients': 

(a)   Dishes    and    toilet    accessories 
to   have  bed  number   placed 
on    each    article    by    stamp, 
paint  or  otherwise 
'b)   Thermometers. 

1.  One  for  each  patient,  to 
be  kept,  if  possible,  in  a 
test  tube  in  a  solution 
of  phenol  or  other  anti- 
septic. 

2.  Linen,  utensils  and  instruments : 

(a)  Appropriately  marked,  and 

(b)  Used  in  wards  and  on  beds  as 

marked. 

E.  Disinfect  and  sterilize:  " 

1.  Latrines  and  toilets  by  having: 

(a)   Seats  and  bowls  waslfed  twice  a  day  with : 

(1)  Hot  soapsuds,  and  a 

(2)  Solution       of       mercuric       chlorid, 

1  :  1.000. 


MANAGEMENT  OF  GONORRHEA      117 

2.  Instruments  and  supplies  by  having : 

(a)  Bed    linen,    towels    and    washable    clothing 

and  other  articles  steam  sterilized  before 
laundering. 

(b)  Metal,  glass  and  rubber  sterilized  in 

(1)  Boiling  water,  or 

(2)  Steam. 

(c)  Silk  and  linen  bougies  and  catheters  steril- 

ized by 

(1)  Washing  with  soap  and  water  after 

using. 

(2)  Immersing  in  solution  of  mercuric 

•  chlorid,  1 :  1,000.  and 

(3)  Rinsing   with    sterile   water  before 

using. 

PATIENTS 

1.  Make  a  Wassermann  blood  serum  test  on  all. 

2.  Treat  no  venereal  sore  until  the  presence  of  syphilis  has 

been  positively  excluded. 

3.  If  dentistry  is  required,  send  to  dental  surgeon  with  the 

diagnosis. 

4.  Allow  light  exercise  when : 

(a)   Urethral  discharge  is  mucopurulent,  scanty  and 
free  from  gonococci. 

(b)  Urine  is  clear,  disregarding  epithelial  shreds. 

(c)  Xo  gonococci  are  found  in  the  expressed  secre- 

tion of  prostate  and  seminal  vesicles. 

5.  Send  to  bed  in  the  hospital  on  the  occurrence  of : 

(a)  Acute  symptoms. 

(b)  Need  for  surgical  interference. 

6.  Diet  to  be  light  and  bland  until  otherwise  ordered. 

7.  Ambulatory  cases  to  wear  suspensory. 


118  THE     VENEREAL     DISEASES 

CLASSIFICATION 

1.  Acute  Gonorrhea. — Fresh  infection. 

(a)  Hyperacute  —  inflammatory    symptoms     excessive, 

marked  edema,  chordee,  burning  urination. 

(b)  Moderately  severe. 

(c)  Mild. 

2.  Chronic  Gonorrhea. 

3.  Complications. 

(a)  Prostatitis : 

1.  Acute. 

2.  Chronic. 

3.  Abscess. 

(b)  Infiltrations  and  strictures: 

1.  Hard. 

2.  Soft. 

(c)  Vesiculitis: 

1.  Acute. 

2.  Chronic. 

(d)  Epididymitis. 
O)   Arthritis. 

(/)   Conjunctivitis. 

METHODS 

1.  Examination  of  patient : 

(a)  Acute  gonorrhea: 

1.  History  taken  on  admission. 

2.  Inspection  of  the  external  genitals. 

3.  Urethral  smears  to  be  prepared,  studied  and 

recorded. 

(b)  Chronic  gonorrhea: 

1.  History  taken  on  admission. 

2.  Inspection  of  the  external  genitals. 


MANAGEMENT  OF  GONORRHEA      119 

3.  Urethral      smears      prepared.      studied      and 

recorded. 

4.  Two-glass  urine  test ;  urine  sedimented ;  sedi- 

ment examined  and  recorded. 

5.  Prostate    and    seminal    vesicles    palpated ;    ex- 

pressed material  collected   for  examination, 
study  and  report. 

6.  Bougie  a  boule  passed  for  stricture  when  indi- 

cated. 

7.  Endoscopy  performed  when  indicated. 

2.  Water  administration  in  : 

(a)  Acute  gonorrhea: 

A  glassful   every  hour  throughout  the  day;   as 
often  as  awake  at  night. 

(b)  Chronic  gonorrhea : 

A  glassful   every  hour  throughout  the  day;   as 
desired  at  night. 

3.  Urination  in : 

(a)   Acute  gonorrhea : 

1.  Bed  urinals  always  at  bedside. 

2.  Patient  to   make   effort  to  pass   urine   hourly 

during  day;  as  often  as  awake  at  night. 

4.  Hand  injections: 

Bed  patients  : 

1.  Hyperacute  type:   none. 

2.  Moderately  severe  type :   every  two  hours   or 

after  each  act  of  urination,  if  irritation  is 
not  produced  by  so  doing 

3.  Mild  type :  every  two  hours  or  after  each  act 

of  urination. 


120  THE     VENEREAL     DISEASES 

5.  Irrigations : 

(a)  Urethra: 

1.  Acute  and  chronic  gonorrhea. 

2.  Gravity  method :  every  second  day. 

3.  Catheter,  not  over   16   French :   when   gravity 

method  is  painful  or  difficult. 

(b)  Bladder: 

1.  Gravity    method :    when    massaged    or    instru- 

mented. 

2.  Catheter. 
Fill  and  empty  two  to  three  times ;  allow  about  2 

ounces  to  remain  in  bladder. 

6.  Massage : 

(a)  Prostate  and  seminal  vesicles : 

1.  Chronic  cases  and  complications : 
(a)  Two  or  three  times  a  week. 

(b)  Urethra  over  sound  : 

1.  Every  other  day  to  twice  a  week. 
(c)  Follow  with  urethrovesical  irrigation. 
(d)   No   massage   on   the   same   day   that   dilatation   is 
performed. 

7.  Dilatation  of  urethra  for: 

(a)   Strictures  by: 

1.  Sounds ;   meatotomy  when  necessary. 

2.  Bougies,  soft. 
3.  Dilators. 

(&)   Follow  with  urethrovesical  irrigation. 

(c)  No   dilatation   on   the   same   day  that   massage   is 

performed. 


MANAGEMENT  OF  GONORRHEA      121 

DRUGS     AXD     SOLUTIONS 

1.  Sandalwood  oil : 

(a)  Dose,  from  0.50  to   1.00  c.c.    (8  to  15  minims)    in 

capsules. 

(b)  Intervals,  three  times  a  day  after  meals. 

(c)  Discontinue  administration  if  it  causes  indigestion 

or  an  intense  pain  in  back. 

(d)  Give  in : 

1.  Hyperacute  type. 

2.  Moderately  severe  type. 

3.  Painful  urination  cases. 

2.  Potassium  permanganate : 

(a)  Aqueous    solution,    strength    from    1 :  5,000    to    1  : 

3.000,    determined    by    reaction    of    the    mucous 
membrane. 

(b)  Use: 

(a)  Fomentation  to  penis  in  hyperacute  cases. 

(b)  Irrigation  of  urethra  and  bladder. 

3.  Silver : 

(a)  Nitrate: 

1.  Aqueous  solution. 

2.  Strength :    from    1 :  10.000    to    1 :  5,000,    deter- 

mined by  reaction  of  the  mucous  membrane. 

3.  Use :   urethral   and  vesical  irrigation. 

(b)  Argyrol  or  equivalent: 

1.  Aqueous  solution. 

2.  Strength :    from  3  to  5  per  cent.,   determined 

by  reaction  of  the  mucous  membrane. 

3.  Dose :  5  c.c.  of  the  solution. 

4.  Interval:   every  two  hours   during   day,   twice 

at  night. 

5.  Use:  urethral  injection. 


122  THE     VENEREAL     DISEASES 

(c)   Protargol  or  equivalent: 

1.  Solution  in  water. 

2.  Strength:    from   0.25   to  0.5   per   cent.,   deter- 

mined by  reaction  of  the  mucous  membrane. 

3.  Dose :  5  c.c.  of  the  solution. 

4.  Interval :   every  two  hours  during  day,  twice 

at  night. 

5.  Used  as  urethral  injection. 

TREATMENT 

1.  Acute  gonorrhea: 

(a)  Hyperacute. 

1.  Confine  to  bed. 

2.  No  injections  until   all   hyperacute   symptoms 

subside. 

3.  Sandalwood  oil  by  mouth. 

4.  Hot  fomentations  to  genitals. 

(b)  Moderately  severe. 

1.  Confine  to  bed. 

2.  Hand  injections,  retained  five  minutes  or  more. 

(a)  After  urination. 

(b)  Every    two    hours    during    day    until   8 

p.  m.  and  at  11  p.  m.  and  3  a.  m. 

2.  Chronic  gonorrheas : 

1.  Massage  prostate  and  seminal  vesicles : 

(a)  Every  other  day  to  twice  a  week  while 

some  urine  is  present  in  bladder. 

(b)  Examine    fluid    expressed    by    massage 

for  gonococci. 

(c)  Examine    sediment    of    urine    collected 

immediately  after  massage 

2.  Irrigation : 

(a)   Ureterovesical. 

1.  Fill    and    empty    bladder    two    or 
three  times. 


MANAGEMENT  OF  GONORRHEA      123 

2.  Allow  about  2  ounces  to  remain  in 
bladder. 
(b)   Every  other  day  to  twice  a  week. 
3.  Complications : 

(a)  Prostate. 

1.  Acute  prostatitis :  See  treatment  of. 

2.  Chronic  prostatitis :  See  treatment  of. 

3.  Abscess :  operation  at  hospital. 

(b)  Seminal  vesicles: 

1.  Acute  vesiculitis:  See  treatment  of. 

2.  Chronic  vesiculitis:  See  treatment  of. 
(r)   Epididymitis:   See  treatment  of. 

1.  Expectant: 

(a)  Stop  all  urethral  treatment. 

(b)  Suspend  testicles. 

2.  Operation  —  epididym'otomy. 

(d)  Cowper's  glands:  See  treatment  of. 

(e)  Urethral  glands:  See  treatment  of. 

(./)   Synovial  membranes:  See  treatment  of. 
{g)   Eyes: 

1.  Conjunctivitis:    Refer  to  ophthalmologist  im- 

mediately. 

2.  Keep  up  treatment  of  urethra  and  adnexa. 
(h)   Chordee:  See  treatment  of. 

TESTS 

Gonorrhea    positive,    gonococci    found    in    smear    and    by 
culture  in: 

(a)  Urethral  discharge. 

(b)  Urinary  sediment  after  massage. 

(c)  Fluid  derived  from  massage. 

1.  Prostate. 

2.  Seminal  vesicles. 


124  THE     VENEREAL     DISEASES 

(d)  Discharge  from  urethral  adnexa  obtained  through 
endoscope. 

2.  Two-glass  test : 

(a)   Urine   voided   in   two   portions   into   two   separate 
containers  : 

1.  One  inch  in  first  glass,  about  one-half  to 

one  ounce. 

2.  Balance  in  second  glass, 
(a)   Deductions : 

1.  Cloudy  first  glass,  pus  sediment;  clear  second 

glass  :  anterior  urethra  only  involved. 

2.  Cloudy  first  glass;    cloudy  second  glass,  pus 

sediment:  posterior  urethra  involved. 

3.  Washings  from  anterior  urethra  clear;  urine 

in  first  and  second  glasses  cloudy,  pus  sedi- 
ment :  posterior  urethra  alone  involved. 

3.  Cure : 

(a)  No  urethral  discharge. 

(b)  Vigorous  exercise  to  be  taken  the  day  before  the 

test  is  made. 

(c)  Urine  not  to  be  voided  for  at  least  two  hours  pre- 

vious to  making  test. 

(d)  Two-glass  test,  both  glasses  to  be  free  from  pus, 

epithelial  filaments  may  be  disregarded. 

O)  Secretions  expressed  from  prostate  and  the  sem- 
inal vesicles  show  few  or  no  leukocytes. 

(/)  Passage  of  bougie  a  boule  demonstrates  absence 
of   stricture. 

SCHEME     OF     EXAMINING     CHRONIC     GONORRHEICS 

In  order  to  standardize  the  method  of  examining  cases  of 
chronic  urethritis,  the  following  system  of  routine  examina- 
tion is  recommended : 


MANAGEMENT  OF  GONORRHEA      125 

The  examination  and  laboratory  notes  can  be  inserted  in 
the  clinical  record  sheets.  The  method  and  sequence  of  the 
steps  of  the  examination  are  indicated  as  follows  : 

Date  : 

Scrotum  and  contents — 

Urethral  secretion — 

Urethral  sec,  Microscope — 

Urine;  glass  1  and  2 

Prostate,  palpation — 

Vesicles,  palpation — 

Exp.  Secretion,  Microscope — 

Urethral  Bougie — 

Ant.  Urethroscopy — 

Post.   Urethroscopy — 

Complications. 

Surname  of  Patient.      Christian    Name. 

The   following  is   a   sample  to   show  clinical   record  filled 
out  with  necessary  clinical  and  laboratory  data  as  obtained 
in  a  hypothetic  case : 
Date  : 
Scrotum  and  contents  : 

(nodule  in  right  epididymis) 
Urethral  secretion : 

Mucopurulent,  moderate  quantity. 
Urethral  secretion,  microscope : 

Pus,  squamous  epithelium ;  moderate  number  of  intra- 
cellular gonococci. 
Urines : 

1.  Turbid  and  shreds. 

2.  Clear. 


126  THE     VENEREAL     DISEASES 

Prostate,  palpation : 

Left  lobe  enlarged  and  nodular. 

Right,  normal  in  size  and  hard. 
Vesicles,  palpation : 

Embedded  in  perivesicular   infiltration. 
Exp.  secretion,  microscope : 

Moderate  amount  of  pus ;  no  organisms. 
Urethra,  Bougie  a  boule : 

No.  24;  stricture  2  inches  from  meatus. 
Anterior  urethroscopy : 

Soft    infiltration,    going    over    into    hard ;    one-half 

dozen   Morgagni's  crypts. 
Posterior  urethroscopy : 

Bleeds  freely;   colliculus,  greatly  congested. 
Complications : 

Arthritis,  left  knee. 

Surname   of   Patient.      Christian    Name. 

INSTRUCTIONS 

1.  Smears  will  be  made  both  from  the  urethra  and  pros- 
tate. One  drop  of  the  discharge  should  be  spread  over  2  cm. 
square  of  slide  or  portion  thereof  in  proportion  to  size  of 
drop. 

2.  The  examination  will  be  made  after  vigorous   exercise 
on  the  day  previous  to  examination,  after  retention  of  urine  j 
for  at  least  two  hours. 

3.  The  cases  will  be  considered  noninfectious : 

(a)  If  there  is  no  discharge  from  the  urethra  or  a 
slight  mucous  discharge  which  is  free  from 
gonococci. 


MANAGEMENT  OF  GONORRHEA      127 

(b)  If  Glasses  I  and  II  are  clear  and  free  from   pus 

shreds.       (Epithelial    filaments    may    be    disre- 
garded.) 

(c)  If  the  secretions  expressed  from  the  prostate  and 

vesicles  show  no  gonococci  and  not  more  than 

five  leukocytes  per  field. 
4.  In  cases  of  doubt  where  no  urethral  discharge  is  present 
a  provocative  irrigation  of  the  urethra  with  silver  nitrate 
1 : 1,000  should  be  made.  If  gonococci  are  still  in  the  tissues 
they  will  be  found  in  the  discharge  which  follows  in  a  few 
hours,  on  microscopic  examination. 

SPECIMEN     OF     THE     FORM     TO     BE     USED     IN     MAKING 
REPORTS     OF     THE     EXAMINATION     OF     SMEARS 
BY     THE     LABORATORY 
Specimen  from : 

URETHRA 

1.  Gonococci. 

(a)  Intracellular. 

(b)  Extracellular. 

2.  Other  organisms. 

3.  Pus. 

4.  Epithelium. 

PROSTATE 

1.  Average  pus  cells  per  field. 

2.  Gonococci. 

(a)  Intracellular. 

(b)  Extracellular. 

3.  Other  organisms. 

4.  Lecithin. 


TREATMENT    OF    GONORRHEA    IN    WOMEN 


GENERAL     CONSIDERATION    AND     PATHOLOGY 

Before  taking  up  the  detailed  treatment  of  gonor- 
rhea in  women  it  seems  best  to  briefly  mention  certain 
facts  in  the  pathology  of  gonorrhea  and  to  give  cer- 
tain general  rules  regarding  treatment  in  order  that 
repetition  may  be  avoided. 

The  pathology  of  this  infection  is  in  great  part 
dependent  upon  the  age  of  the  patient.  During  men- 
strual life,  the  initial  lesions  are  most  often  an  endo- 
cervicitis  and  less  commonly  a  urethritis ;  infection  of 
the  glands  of  the  introitus  are  secondary  and  vaginitis 
is  exceptional  in  this  age.  During  this  period  of  life, 
there  is  a  probability  of  ascension  of  the  infection  to 
the  uterine  body  and  tubes.  This  ascension  is  most 
liable  to  occur  during  the  act  of  menstruation,  where 
the  uterus  is  congested  and  the  os  dilated.  It  is  there- 
fore highly  advisable  that  patients  with  gonorrhea 
remain  in  bed  during  menstruation,  especially  if  the 
disease  is  still  acute. 

Before  puberty  and  after  the  menopause  the  vaginal 
mucosa  is  not  so  resistant  to  infection,  so  that  in  these 
extremes  of  age  vaginitis  is  the  common  lesion. 
Before   puberty   this   vaginitis   is   associated   with    a 


GONORRHEA     IN     WOMEN  129 

vulvitis,  but  after  the  menopause  the  vulva  is  not  so 
liable  to  be  infected  as  are  the  cervix  and  urethra. 
These  cases  of  vaginitis  are  extremely  resistant  to 
treatment,  as  is  also  the  endocervicitis  of  the  atrophic 
uterus. 

Pregnancy  also  alters  the  pathology  of  gonorrhea. 
There  is  commonly  a  vaginitis  associated  with  marked 
roughening  of  the  vaginal  walls,  and  condylomata 
acuminata  are  prone  to  occur.  Gonorrhea  always 
increases  the  possibility  of  premature  emptying  of  the 
uterus  and  vigorous  treatment  likewise  increases  the 
danger.  Therefore,  treatment  must  be  gently  applied. 
Douches  must  be  of  tepid  water  instead  of  hot  and 
low  pressure  should  be  insisted  on.  Topical  appli- 
cations to  the  cervix  had  best  be  omitted.  The  exci- 
sion of  condylomata,  the  cauterization  of  ulcers,  and 
the  incision  of  vulvar  abscesses  may  institute  abortion. 
Any  of  these  procedures  should  if  possible  be  avoided, 
for  it  is  greatly  to  the  patient's  interest  that  abortion 
should  not  occur  during  the  acute  stage  of  the  disease. 

Douches  given  during  gonorrhea  should  not  be  too 
hot,  else  the  damage  done  by  the  heat  increase  the 
area  of  involvement.  A  temperature  of  110  degrees 
produces  enough  heat  to  relieve  pain,  dissolve  secre- 
tions and  improve  the  local  circulation.  Douches 
should  be  copious,   six  to  eight   quarts   of  water,  in 


130  THE     VENEREAL     DISEASES 

order  that  the  action  time  of  the  medication  may  be 
increased  and  because  a  prolonged  irrigation  relieves 
pain  more  than  does  a  short  one,  and  is  less  liable  to 
induce  bleeding.  The -douche  should  never  be  given 
under  high  pressure,  especially  during  the  acute  stage, 
as  it  may  force  infection  into  higher  regions  and  may 
produce  harmful  massage.  Ordinarily  the  bottom  of 
the  douche  bag  should  not  be  over  a  foot  above  the 
level  of  the  hips.  During  the  infective  stage,  the 
douches  should  be  taken  while  lying  on  a  pan,  since  it 
is  dangerous  to  others  to  take  it  while  sitting  on  the 
toilet  or  lying  in  the  bath-tub.  Douches  should  be 
omitted  during  menstruation,  but,  if  they  are  given, 
especially  low  pressure  should  be  prescribed,  with  a 
temperature  between  95  and  100  degrees,  so  as  not  to 
increase  the  chances  of  ascending  infection  or  hem- 
orrhage. 

No  rectal  examination  should  be  made  nor  enemata 
given,  because  of  the  danger  of  producing  a  gonor- 
rheal proctitis. 

During  the  disease,  of  course,  coitus  should  be  pro- 
hibited, not  only  that  the  man  may  not  become  infected 
but  because  the  resulting  trauma  may  be  absolutely 
dangerous,  or  at  least  delay  the  cure.  Complete 
directions  should  be  given  each  patient  in  order  that 
others  may  not  be  innocently  infected.     No  nurse  nor 


GONORRHEA     IN     WOMEN  131 

other  person  having  to  do  with  the  care  of  children. 
who  has  gonorrhea,  should  be  allowed  to  continue  in 
her  work  because  of  the  liability  of  direct  implanta- 
tion of  the  disease  by  the  necessary  attention  to  the 
toilet  of  children. 

ACUTE      CERVICITIS     AXD     EXDOCERVICITIS 

A  large  douche  of  plain  hot  water  followed  by  two 
quarts  of  1  :  2,000  silver  nitrate  or  potassium  perman- 
ganate, may  be  given  three  or  four  times  a  day  during 
the  period  of  profuse  discharge.  This  water  does  not 
enter  the  cervical  canal  and  kill  the  gonococci,  but  it 
does  furnish  heat  of  therapeutic  value  and  cleanses 
the  vagina  of  irritating  discharges  which  tend  to 
macerate  the  cervical  and  vaginal  mucosa.  By  wash- 
ing away  the  infective  organisms,  it  also  minimizes 
the  danger  of  infection  of  the  Bartholinian  glands, 
the  urethra  and  the  peri-urethral  ducts,  if  these  are 
not  already  involved. 

After  douching  for  two  weeks,  the  acuteness  of  the 
reaction  in  the  cervical  canal  is  generally  so  greatly 
reduced  that  topical  applications  may  be  made.  At 
this  time  the  cervix  still  gapes,  but  the  cervical  secre- 
tion has  lost  much  of  its  purulent  color  and  is  more 
albuminous  in  character.  After  the  cervical  canal  is 
swabbed  as  dry  as  possible,  silver  nitrate  10  per  cent. 


132  THE     VENEREAL     DISEASES 

or  pure  tincture  of  iodin  is  applied  to  the  lower  three- 
quarters  of  an  inch  of  the  cervical  canal.  These 
applications  are  made  twice  a  week  until  the  cervix  is 
practically  free  of  mucus  or  until  the  cervical  canal 
has  returned  to  normal  caliber,  it  being  understood 
that  the  gonococci  have  not  been  found  on  repeated 
examination.  Should  bleeding  result  from  these 
treatments,  it  indicates  that  the  swabs  have  been  intro- 
duced too  deeply  or  that  the  condition  is  still  too  acute 
for  topical  application. 

CHRONIC     ENDOCERVICITIS     AND     CERVICITIS 

The  above  outlined  treatment  should  be  carried  out, 
increasing  the  strength  of  the  topical  application  of 
silver  nitrate  to  20  per  cent.  Erosions  of  the  cervix 
should  be  painted  with  this  same  solution.  After  all 
active  evidence  of  inflammation  has  subsided,  super- 
ficial cauterization  of  erosions  may  have  to  be  per- 
formed, in  order  to  rid  a  patient  of  an  irritating 
discharge.  When  closure  of  the  ducts  of  the  mucous 
glands  results  in  numerous  Nabothian  follicles,  these 
are  best  treated  by  destruction  with  a  fine-pointed 
electric  or  Paquelin  cautery.  This  may  be  done  in 
the  office,  care  being  taken  not  to  do  too  much  in  one 
sitting  and  to  allow  sufficient  time  between  treatments 


GONORRHEA     IN     WOMEN  133 

for  healing  to  occur.  In  aggravated  cases,  under  spe- 
cial conditions,  the  gland-bearing  portion  of  the  cervix 
may  be  excised  by  operation.  This,  of  course,  would 
only  become  necessary  months  after  the  time  of  the 
acute  infection. 

VAGINITIS 

During  the  acute  stage,  vaginitis  is  to  be  treated  by 
douches  as  outlined  above.  Soft  tampons  of  cotton 
soaked  in  1  :  200  silver  nitrate  solution  may  be  gently 
inserted  in  the  vagina  by  the  physician  and  removed 
by  the  patient  after  two  to  four  hours.  If  too  much 
pain  results,  protargol  5  per  cent,  or  argyrol  10  per 
cent,  may  be  substituted  for  the  silver  nitrate.  When 
the  edema  has  disappeared,  topical  applications  may 
be  made  directly  to  the  vaginal  wall.  Silver  nitrate 
10  per  cent,  is  painted  over  the  cervix  and  the  vaginal 
wall  in  its  entirety,  care  being  taken  not  to  let  an  excess 
of  silver  nitrate  run  down  upon  the  vulva.  It  is  well 
to  insert  a  pledget  of  cotton  just  inside  the  vaginal 
entrance  immediately  after  this  treatment ;  this  may 
be  removed  by  the  patient  just  before  the  next  douche. 
If  stubborn  spots  or  ulcers  persist,  the  cautery  should 
be  lightly  applied.  Condylomata  are  best  removed  by 
the  galvanocautery,  a  few  at  a  time,  unless  the  patient 
is  to  remain  in  bed  under  attention. 


134  THE     VENEREAL     DISEASES 

VULVITIS 

Rarely  does  a  vulvitis  exist  without  disease  farther 
up  the  genital  canal,  but,  if  it  does,  care  should  be 
exercised  not  to  spread  the  infection  upward.  During 
the  acute  stage,  rest  in  bed  is  usually  required  by  the 
patient's  discomfort.  Acetylsalicylic  acid  or  pyramidon 
is  generally  sufficient  to  control  the  pain.  An  ointment 
of  protargol  5  per  cent.,  spread  on  gauze,  may  be 
applied  to  the  vulva,  and  if  itching  is  present,  y2  per 
cent,  phenol  is  added  to  the  ointment. 

In  chronic  cases,  the  infected  Bartholinian  and  para- 
urethral ducts  are  to  be  injected  through  a  blunt 
hypodermic  needle  with  10  to  20  per  cent,  silver  nitrate 
and  the  vulva  painted  with  2  to  5  per  cent,  solution. 

BARTHOLINITIS 

Hot  applications  should  be  made  during  the  acute 
stage  of  a  bartholinitis ;  and  rest  in  bed  with  sedatives 
is  to  be  prescribed  for  pain.  Just  as  soon  as  an 
abscess  has  formed  it  should  be  incised  and  drained 
and  only  if  drainage  persists  or  exacerbations  occur 
should  the  gland  be  removed.  A  cystic  or  chronically 
infected  gland  should  always  be  excised  instead  of 
drained,  but  considerable  danger  attends  the  practice 
of  removing  by  dissection  acutely  inflamed  glands. 


GONORRHEA    IN     WOMEN  135 

URETHRITIS 

This  is  not  always  present  in  gonorrhea  in  the 
female  and  many  cases  run  their  entire  course  'without 
any  urinary  disturbance.  When  present  it  is  fre- 
quently of  short  duration,  not  very  distressing  and 
cures  itself  spontaneously.  The  burning  on  urination 
may  be  lessened  by  sandal  oil  and  by  copious  drinking 
of  fluids,  and  the  attack  may  be  shortened  by  acidifi- 
cation of  the  urine.,  and  hexamethylenamin.  a  dram  a 
day  in  divided  doses.  When  the  genital  tract  is 
invaded,  as  it  usually  is.  the  prolonged  hot  douches 
advised  elsewhere  furnish  much  relief  from  the  pain. 

In  subacute  cases,  bougies  three  quarters  of  an  inch 
long,  of  10  per  cent,  argyrol  or  5  per  cent,  protargol  in 
cocoa  butter,  may  be  inserted  by  the  physician  and  the 
patient  instructed  in  this  insertion.  These  bougies 
should  be  inserted- after  urination  and  held  in  position 
until  they  tend  not  to  escape. 

In  chronic  cases,  the  urethra  mav  be  lightly  mas- 
saged  before  urination ;  this  tends  to  empty  the  crypts 
along  the  urethral  canal  and  hastens  the  absorption  of 
inflammatory  deposits.  If  this  massage  is  followed 
by  an  exacerbation  of  symptoms,  it  has  been  begun 
too  early.  In  stubborn  cases,  an  endoscope  should  be 
inserted,  and  silver  nitrate  10  per  cent,  be  lightly 
applied  to  the  inflamed  areas ;   this   failing,   a    sound 


136  THE     VENEREAL     DISEASES 

just  large  enough  to  distend  the  urethra  should  be 
coated  with  protargol  ointment  10  per  cent,  and 
inserted,  and  light  massage  of  the  urethra  carried  on ; 
this  is  done  twice  a  week.  The  bladder  should  be  full 
during  this  treatment  and  then  emptied  immediately. 
Stricture  of  the  urethra  is  a  rare  complication,  but 
should  be  suspected  in  cases  with  recurrent  symptoms, 
especially  if  associated  with  difficulty  in  urination. 
The  treatment  of  stricture  is  the  same  as  in  the  male, 
but  is  much  more  readily  performed. 

If  Skene's  or  the  para-urethral  ducts  remain  infected, 
recurring  difficulty  may  be  expected.  If  injection  of 
10  per  cent,  silver  nitrate  through  a  blunt  hypodermic 
needle  does  not  perfect  a  rapid  cure,  then  with  a 
probe  as  a  guide,  a  galvanocautery  should  be  used  to 
destroy  the  crypts  in  their  entirety. 

CYSTITIS 

Cystitis  in  the  female  is  not  existent  as  often  as 
treated ;  but  when  actually  demonstrated  to  be  present, 
the  treatment  is  the  same  as  in  the  male. 

METRITIS     AND     ENDOMETRITIS 

During   the   acute    stage,    rest   in   bed   is    strictly 
advised.      Hot   or   cold   applications   over   the   lower 
abdomen    are    to    be    given    for    the    relief    of    pain. 


GONORRHEA     IN     WOMEN  137 

Acetylsalicylic  acid  (aspirin)  and  pyramidon  or  other 
analgesics  may  be  prescribed,  but  rarely  are  opiates 
necessary.  When  extreme  pain  is  present,  it  gener- 
ally indicates  that  tubal  involvement  has  already 
occurred.  Hot  douches,  as  advised  in  endocervicitis, 
are  to  be  ordered,  but  local  applications  are  absolutely 
inadvisable  and  dangerous  during  the  acute  stage.  In 
the  event  of  menstruation  occurring  during  the  acute 
stage,  ergot  should  be  given  in  order  to  diminish 
bleeding. 

When  the  disease  has  become  chronic  in  the  uterus, 
treatment  depends  upon  symptomatology.  The  knowl- 
edge that  gonorrhea  has  existed  does  not  indicate 
treatment.  If  menorrhagia  occurs  and  is  not  brought 
under  control  by  a  prolonged  course  of  hot  douches 
and  ergot,  a  curettage  followed  by  a  liberal  intra- 
uterine application  of  tincture  of  iodin  is  indicated. 
If  tubal  involvement  is  also  present,  curettement  is 
not  to  be  performed,  unless  at  the  same  time  surgery 
for  the  relief  of  the  tubal  condition  is  to  be  carried 
out.  Hemorrhage  is  the  only  indication  for  a  curet- 
tage. It  is  not  to  be  performed  with  the  idea  of 
cleansing  the  uterus  of  gonorrheal  disease ;  if  gono- 
cocci  can  be  demonstrated  in  the  cervical  discharge,  a 
curettage  can  only  harm  the  patient. 


138  THE     VENEREAL     DISEASES 

A  leukorrhea  of  gonorrheal  origin  indicates  that  the 
chief  infection  lies  in  the  cervical  canal  and  a  curet- 
tage would  only  make  the  patient  worse.  Intra- 
uterine applications  of  caustics  or  other  destructive 
agents  are  unsurgical  and  provocative  of  harm.  Time 
is  an  important  factor,  since  many  cases  of  uterine 
infection  progress  to  a  cure  despite  unsuccessful  treat- 
ment. Many  cases  may  require  surgery,  but  time  is 
of  first  importance. 

SALPINGITIS     AND     OVARITIS 

Absolute  rest  in  bed  and  quiet  are  the  principal 
therapeutic  agents  during  the  acute  stage.  Although 
pyramidon  and  acetylsalicylic  acid  help  greatly  in  the 
control  of  the  pain,  which  is  severe,  opiates  are  usually 
necessary  to  supplement  their  action.  The  bowels 
should  be  moved  by  laxatives  instead  of  enemas  because 
of  the  danger  of  proctitis,  and  because  harmful  pressure 
on  incompletely  closed  tubes  may  lead  to  a  leakage  of 
pus.  The  practice  of  purging  such  patients  is  harmful, 
since  it  disturbs  rest,  increases  pressure  and  weakens 
the  patient.  Examinations  should  be  very  gently  per- 
formed and  limited  to  absolute  necessity,  since  exacer- 
bations in  temperature  and  pain  frequently  follow 
them.  Douches  given  during  the  acute  stage  are  more 
often  followed  by  harm  than  by  good  and  should  be 


GONORRHEA     IN     WOMEN  139 

held  in  abeyance  until  adhesions  are  surely  strong  and 
resistant. 

Abundant  easily  digested  food  is  necessary,  if  food 
is  tolerated;  the  appetite  should  be  encouraged,  and 
better  sleep  induced. 

The  onset  of  the  infection  is  usually  stormy,  but 
improvement  occurs  rapidly;  the  fever  tends  to 
decrease  after  three  or  four  days  and  the  pain  lessens. 
If  at  the  end  of  a  week  the  fever  remains  high  and 
pain  persists,  there  may  be  found  definite  palpable 
swellings  of  the  appendages.  If  the  patient  is  not 
improving,  these  swellings  should  be  drained  vaginally, 
care  being  taken  not  to  traverse  the  peritoneal  cavity. 
The  early  drainage  of  pus  allows  early  resolution  and 
limits  the  destruction  of  tissue.  Cases  so  drained  are 
less  often  in  need  of  subsequent  surgery,  and  more 
frequently  progress  to  a  complete  anatomical  cure. 
Of  course,  cases  which  are  getting  well  without  sur- 
gery should  be  let  alone.  Abdominal  surgery  is  too 
often  done  during  the  acute  and  subacute  stages  of  the 
disease.  The  patients  run  more  danger  from  these 
operations  than  they  do  from  the  disease,  since  general 
peritonitis  is  a  rare  complication  of  gonorrheal  sal- 
pingitis and  is  too  often  a  termination  of  these  opera- 
tions. 


140  THE     VENEREAL     DISEASES 

If  the  pain  and  swellings  persist  after  the  tempera- 
ture has  subsided,  then  douches  should  be  given. 
Icthyol  5  per  cent,  in  glycerin  applied  on  tampons  in 
the  vault  of  the  vagina  is  a  valuable  agent  in  hastening 
resolution  in  the  inflamed  appendages. 

If  pain  persists  after  leukocytosis  has  disappeared, 
much  relief  can  be  had  by  the  use  of  dry  heating  of 
the  pelvic  region  by  some  of  the  various  special  cabi- 
nets arranged  for  this  purpose. 

As  long  as  progressive  improvement  occurs  the 
patient  should  not  be  operated  on  and  the  practice  of 
operating  on  such  patients  because  they  have  abnormal 
anatomy  should  be  discouraged.  It  frequently  happens 
that  even  big  bilateral  swellings  not  only  progress  to 
an  anatomical  cure,  i.  e.,  disappearance  of  the  swell- 
ings and  a  return  of  the  organs  to  normal  palpatory 
findings,  but  also  to  a  physiological  cure  as  shown  by 
the  occurrence  of  pregnancy.  Where  exacerbations 
of  acute  difficulty  occur  or  where  there  is  an  impor- 
tant residue  of  pain  or  menorrhagia  after  weeks  or 
months  have  elapsed,  and  where  these  conditions  are 
more  appropriately  treated  by  surgical  measures,  their 
further  treatment  is  by  direct  surgical  attack,  which 
must  be  conducted  by  a  trained  surgeon. 


APPENDIX 


WAR  PROGRAM  OF  THE  SURGEON- 
GENERAL  OF  THE  ARMY  FOR 
COMBATING  VENEREAL 
DISEASES 


The  following  program  is  the  working  plan  under 
which  the  activities  of  the  Surgeon-General's  Office  for 
attacking  venereal  diseases  have  been  coordinated  and 
developed.  Eighteen  months'  experience  with  it  dur- 
ing the  war  has  proved  its  value  and  practicability. 


PROGRAM     OF     ATTACK     ON 
VENEREAL     DISEASES 


AN     OUTLINE    OF     ACTIVITIES     AND     COOPERATING     AGENCIES 

PLANNED    TO    REDUCE    THE    PREVALENCE    OF 

THE    VENEREAL    DISEASES 

Methods  of  attack  on  venereal  diseases  divide  themselves 
into  four  classes : 

A.  Social  measures  to  diminish  sexual  temptations. 

B.  Education  of  soldiers  and  civilians  in  regard  to  venereal 
diseases. 

C.  Prophylactic  measures  against  venereal  diseases. 

D.  Medical  care. 

A.     SOCIAL     MEASURES      TO     DIMINISH     SEXUAL     TEMPTATIONS 

(1)  The  suppression  of  prostitution  and  the  liquor  traffic. 

(2)  Provision  of  proper  social  surroundings  and  recreation. 

These  activities  which  have  to  do  with  social  matters 
largely  fall  outside  the  jurisdiction  of  the  medical 
service  of  the  Army,  but  this  service  can  render  these 
activities  more  efficient  by  stimulating  and  support- 
ing them,  and  wherever  practicable  such  support 
should  be  given. 

(1)  Suppression  of  prostitution  and  liquor  traffic  in  zones. 

Keep  careful  track  of  conditions  as  regards  these  two 
matters  in  surrounding  districts,  in  cities  or  towns 
where  soldiers  go,  and  in  travel  gateways. 

In  camps  and  zones,  we  have  the  following  agencies  which 
may  be  utilized : 


144  THE     VENEREAL     DISEASES 

The  constituted  authorities,  military  and  civil. 

The    Commission    on    Training    Camp    Activities,    War 

Department. 
Local   and  national  volunteer  agencies   may  be  utilized 

to  discover  fauares  and  abuses,  and  to  help  otherwise 

in  the  work  under  direction  of  the  proper  authorities. 
Outside  the  zones,  a  large  number  $f  forces  can  be  used. 

Among  these : 
State  Councils  of  National  Defense. 
Civil,  police  and  health  administrations. 
Associations  of  commerce. 
Women's  clubs. 
The  press. 
Social  hygiene  and  vigilance  societies,  and  other  social 

and    religious    organizations    of    influence    in    civil 

communities. 

(2)  Provision  of  proper  social  surroundings  and  recreation. 

In  camps  and  zones,  plan  to : 

Develop   social   activities   and   amusements. 

Provide  places  where  soldiers  may  go  for  comradeship, 
to  meet  friends,  to  "loaf." 

Supply  an  attractive  place,  or  places,  for  soldiers  to  meet 
their  women  callers  in  camps  and  near  camps. 

Establish,  under  police  authority,  women  patrols  in  zones. 

Enforce  rules  against  women  being  received  in  soldiers' 
tents  or  being  allowed  the  freedom  of  camps. 

Encourage  facilities  for  interesting  the  soldier  in  read- 
ing,  lectures,   music,   congenial   friendships,   hobbies. 

For  this  purpose,  we  have  for  use  in  camps  or  zones,  or 
both: 

The  Commission  on  Training  Camp  Activities,  supervis- 
ing activities  of  the  Young  Men's  Christian  Associa- 
tion,     Playground      and      Recreation      Association, 


PROGRAM     OF     ATTACK  145 

Knights  of  Columbus,  Young  Women's  Christian 
Association  through  its  hostess  houses,  the  American 
Social  Hygiene  Association,  and  other  national  and 
local  organizations  invited  to  carry  on  special 
activities. 

Similar  provisions  for  social  diversions  and  proper  social 
surroundings  should  be  provided  outside  the  zones, 
and  if  possible,  provision  at  least  for  their  inspection 
by  military  inspectors  should  be  provided. 

For  use  outside  the  zones,  we  have  practically  all  the 
above  agencies  which  are  organized  to  conduct  similar 
work  in  communities  accessible  to  soldiers  but  not 
within  the  military  zones. 

An  effort  should  be  made  to  stimulate  local  organiza- 
tions in  towns  near  camps  and  at  railroad  centers  to 
furnish  proper  social  diversions  and  amusements  for 
soldiers,  and  to  provide  places  where  they  may  go 
when  on  leave. 

Enlisted  men's  clubs  for  this  purpose,  perhaps  charging 
a  small  fee,  say  25  cents  monthly  membership,  are 
greatly  to  be  desired. 

Organizations  of  men  and  mature  women  to  furnish  mem- 
bers to  meet  soldiers  in  a  friendly  way,  and  to  give 
them  information  and  directions  are  desirable  in 
towns  and  at  railroad  centers  and  other  points  in 
large  cities  where  soldiers  come  in  numbers.  Fra- 
ternal organizations  should  be  enlisted  in  this  work. 

Pressure  should  be  brought  to  bear  on  the  civil  authori- 
ties to  suppress  vicious  amusement  places,  to  clean 
up  parks  and  other  recreation  places,  and  to  furnish 
for  such  places  morals  police.  For  this  purpose,  the 
members  of  special  law  enforcement  organizations 
can  be  used. 


146  THE     VENEREAL     DISEASES 

Inspection  of  social  and  moral  conditions  in  the  camps, 
in  the  zones,  and  in  contiguous  districts  and  of  the 
work  being  done  by  the  various  agencies  for  social 
betterment  should  be  made  by  federal  authorities. 
Similar  volunteer  inspections  by  dependable  vigilance 
and  other  civic  associations  should  be  encouraged. 

B.     EDUCATION     OF     SOLDIERS     AND     CIVILIANS 

(1)  For  Soldiers:  (a)  Lectures;  (b)  Pamphlets;  (c)  Exhibits. 

(a)  Lectures  to  soldiers  should  be  given  by  medical  and 
line  officers  and  by  competent  volunteers  furnished 
by  outside  agencies,  under  invitation  and  direction  of 
the  Medical  Department.  These,  besides  inculcating 
continence,  should  explain  the  risk  and  waste  of  vene- 
real diseases  and  the  program  adopted  to  avoid  them. 
Lectures  without  authority  should  not  be  permitted. 

(b)  A  pamphlet  should  be  given  the  soldier  as  soon  as 
possible  after  enlistment.  This  pamphlet  should  be 
very  brief  and  should  warn  the  soldier  of  the  vene- 
real dangers  to  which  he  may  be  exposed,  and  give 
instructions,  if  he  should  be  exposed,  to  report  as 
promptly  as  possible  to  his  regimental  infirmary. 
It  would  be  very  desirable  if  a  pamphlet  could  be 
distributed  at  the  place  of  meeting  of  Exemption 
Boards.  Later  somewhat  fuller  pamphlets  should  be 
distributed  to  soldiers  through  medical  and  line 
officers,  or  by  accredited  volunteer  social  hygiene 
societies. 

(c)  Exhibits,  such  as  the  Coney  Island  exhibit  of  the 
New  York  Society  of  Social  Hygiene,  the  exhibit  of 
the  National  Cash  Register  Company,  the  exhibits  of 
the  Oregon  Social  Hygiene  Society,  the  Missouri 
Society  and  other  exhibits  and  demonstration  methods 


PROGRAM     OF     ATTACK  147 

worked  out  by  the  American  Social  Hygiene  Asso- 
ciation should  be  adapted  to  the  needs  of  military 
life  and  furnished  to  each  cantonment. 

(2)  For  Civilians: 

In  the  attack  on  the  venereal  problem,  it  is  highly  desir- 
able that  such  educational  activities  as  those  outlined 
above  for  soldiers  should  be  stimulated  for  the 
civilian   population. 

The  influence  of  the  military  authorities  should  be  given 
to  the  national  organizations  for  social  hygiene  and 
to  the  numerous  sanely  conducted  local  organizations 
of  the  same  sort. 

Encouragement  should  be  given  to  the  organizations 
which  are  undertaking  to  arouse  the  interest  of  the 
woman  population  of  the  country  in  matters  of  social 
hygiene  and  for  instructing  women  in  regard  to 
venereal  diseases. 

Organizations  dealing  with  these  matters  which  attempt 
to  reach  women  should  be  encouraged,  especially  in 
the  vicinity  of  camps.  An  increasing  number  of 
influential  organizations,  such  as  the  General  Federa- 
tion of  Women's  Clubs  and  Patriotic  Women's 
League,  are  indorsing  and  supporting  sound  social 
hygiene  programs,  and  supplementing  the  more  spe- 
cialized efforts  of  such  organizations  as  the  Young 
Women's  Christian  Association  and  the  Women's 
Christian  Temperance  Union. 

C.    PROPHYLACTIC   MEASURES 

Instruction  in  Prophylaxis: 

Soldiers  should  be  informed  of  the  fact  that  there  are 
prophylactic    measures    that    reduce    the    dangers    of 


148  THE     VENEREAL     DISEASES 

venereal  infection.  But  this  instruction  should  take 
particular  care  to  inform  them  that  there  are  limita- 
tions to  such  prophylactic  measures  and  that  they 
furnish  only  partial  protection  and  in  no  sense  give 
freedom  from  risk. 

Regimental  Infirmaries: 

The  provision  of  prophylaxis  (early  treatment)  in  regi- 
mental infirmaries,  which  should  be  open  day  and 
night,  is  imperative  in  any  sane  attack  on  venereal 
diseases.  The  prophylactic  station  should  be  utilized 
as  a  place  for  personal  advice  and  education  against 
future  exposure,  and  should  be  conducted  as  an  early 
treatment  dispensary.  Any  spirit  of  levity  or  con- 
doning sexual  promiscuity  should  be  discouraged,  and 
obscene  stories  or  objectionable  conduct  should  be 
rigidly  repressed.  The  men  assigned  as  officers  in 
charge  of  these  stations  should  be  mature  and  with 
the  personality  and  force  of  character  calculated  to 
gain  the  confidence  and  respect  of  the  men  applying 
for  treatment.  The  medical  officer  in  command  should 
be  impressed  with  the  strategic  importance  of  the 
prophylactic  station  for  education,  appeal,  and  the 
securing  of  social  facts  of  vital  importance  in  the 
prevention  of  venereal  diseases. 

Infirmaries  in  Civil  Centers: 

In  cities,  where  there  are  no  adequate  civil  dispensaries 
to  be  used  and  through  which  soldiers  in  consider- 
able numbers  pass,  either  while  on  leave  or  in  travel, 
there  should  be  provided  in  accessible  locations  regi- 
mental infirmaries.  In  a  few  cities,  where  dispensary 
services  are  particularly  well  developed,  regimental 
infirmaries  may  be  replaced  to  advantage  by  accredit- 


PROGRAM     OF     ATTACK  149 

ing  these  civil  dispensaries  for  use.  Information 
should  be  furnished  to  soldiers  of  the  existence  and 
location  of  such  regimental  infirmaries  and  available 
dispensaries. 

Leaves  of  Absence.  In  the  interest  of  health,  long  leaves 
of  absence  for  soldiers  should  as  far  as  possible  be 
discouraged.  Leaves  of  absence  of  more  than  twenty- 
four  hours  are  particularly  dangerous,  and  it  would 
be  desirable  if  leaves  of  absence  should  be  timed 
from  as  early  an  hour  in  the  day  as  possible. 

In  cases  where  soldiers  have  been  exposed,  particularly 
if  for  any  reason  exposure  seems  unusually  danger- 
ous, special  observation  of  such  exposed  men  should 
be  made,  and  if  practicable  these  observations  should 
be  repeated  at  intervals  of  a  couple  of  days  for  two 
or  three  weeks. 

All  pressure  possible  should  be  made  by  military  authori- 
ties against  houses  or  women  which  experience  shows 
are  frequent  sources  of  infection,  and  this  should  be 
extended  as  far  as  practical  to  prostitution  generally. 
The  more  effective  the  repression  of  prostitution  can 
be  made  the  greater  will  be  the  reduction  in  venereal 
diseases. 

All  possible  influences  should  be  brought  to  bear  to 
encourage  civil  authorities  in  the  attack  on  prostitu- 
tion in  all  its  phases.  A  medical  program  for  civil 
communities  equivalent  to  the  military  program  for 
prevention  and  treatment  should  be  encouraged. 

D.     MEDICAL    CARE 

hospital  Organization: 

There  should  be  a  special  service  in  each  cantonment 
hospital  to  care  for  skin  and  venereal  diseases. 


150  THE     VENEREAL     DISEASES 

As  far  as  possible,  all  such,  cases  should  be  in  charge  of 
the  venereal  service,  and  where,  for  any  special  rea- 
sons, such  cases  must  be  under  other  services,  the 
senior  officer  of  the  venereal  services  should  be,  if 
possible,  consulted  in  regard  to  them. 

In  the  venereal  disease  service,  there  should  be  at  the  head 
an  experienced  specialist  in  these  diseases,  and  when- 
ever possible  another  medical  officer  trained  in  vene- 
real diseases  should  also  be  in  the  service.  The 
other  medical  officers  assigned  to  the  service  need 
not  necessarily  at  the  beginning  be  trained  in  venereal 
diseases. 

In  the  event  that  mature  specialists  from  the  Medical 
Officers'  Reserve  Corps  cannot  be  furnished  for  the 
head  of  the  service  in  each  one  of  the  cantonment 
hospitals,  it  would  be  practicable  to  use  two  half-time 
men,  serving  on  alternate  days,  to  act  as  head  of 
this  service,  these  men  to  be  obtained  from  adja- 
cent large  cities.  Under  such  conditions,  there  should 
always  be  furnished  a  qualified  junior  officer. 


Instruction  in  Venereal  Disease  for  Medical  Officers: 

.  One  of  the  important  functions  of  these  services  will  b 
to  train  a  group  of  men  in  venereal  diseases.  The 
service  will,  if  well  conducted,  rapidly  develop  the 
knowledge  of  these  diseases  among  medical  officers. 

It  should  be  distinctly  understood  that  one  of  the  duties 
of  the  trained  specialists  who  go  into  this  service 
will  be  that  of  teachers  of  venereal  diseases  to  the 
less  well  trained  medical  officers,  and  regimental  offi- 
cers should  be  encouraged  to  avail  themselves  of  the 
opportunity  for  instruction  furnished  by  these  services. 

Emphasis  should  be  placed  on  the  necessity  of  high  stand- 
ards of  technic  in  carrving  out  treatment. 


. 


PROGRAM     OF     ATTACK  151 

Hospital  Cases: 

The  cantonment  hospital  should  have  under  its  care  all 
cases  of  venereal  diseases  which  are  in  the  acute, 
infectious  stages.     These  include: 

All  cases  of  acute  gonorrhea. 

All  cases  of  syphilis  during  the  early  infectious  stage 
and  which  have  chancres,  mucous  patches,  or  con- 
dylomata. 

But  it  should  be  seen  to  that  hospitalization  of  venereal 
disease  does  not  become  an  abuse  which  is  allowed 
to  interfere  unduly  with  military  duty. 

There  should  be  no  leaves  of  absence  for  infectious  vene- 
real cases,  and  cases  which  have  passed  the  acute 
infectious  stage  but  which  might  become  dangerous 
through  the  possible  development  of  mucous  patches 
or  of  chronic  gonorrheal  discharge  should  not  be 
allowed  leaves  of  absence  from  camp. 

Standard  Records: 

The  syphilitic  register  of  the  army  should  be  carefully 
and  fully  kept  and  social  facts  of  epidemiologic 
importance  should  be  secured  in  every  case  if  possible. 

Standardised  Treatment: 

An  effort  should  be  made  to  standardize  in  a  general  way 
methods  of  treatment,  and  provision  should  be  made 
for  some  special  instructions  in  venereal  diseases  for 
all  medical  officers  who  have  charge  of  troops.  To 
this  end,  a  manual  of  instructions  should  be  issued 
to  each  of  the  medical  officers  in  the  army.  This 
should  especially  emphasize  the  great  importance  of 
early  diagnosis  and  treatment  in  venereal  diseases 
and    outline   suitable   methods    of   treatment. 


152  THE     VENEREAL     DISEASES 

There  should  be  furnished  cards  of  brief  instruction  to 
patients  with  gonorrhea  or  syphilis. 

Laboratory  Facilities: 

Laboratory  facilities  are  necessary: 

(1)  For  demonstrating  gonococci  and  other  bacteria. 

(2)  For  demonstrating  spirochetes  by  dark  field  illumi- 

nation. 

(3)  For   urinalysis    (which    should   be    required   once   a 

week  for  every  syphilitic  patient  under  treatment). 
These  laboratory  facilities  should  be  in  the  wards  of 
the  venereal  service. 

(4)  For  Wassermann  tests. 

These  to  be  in  the  general  laboratory. 

Inspections: 

In  order  to  keep  up  a  high  standard  of  effectiveness,  there 
should  be  provision  for  inspection  of  these  services  by 
special  inspectors  in  venereal  diseases  from  the  Sur- 
geon-General's Office.  These  inspections  should  cover 
each  of  the  four  classes  of  attack  specified. 


INSTRUCTIONS     FOR     THOSE     HAVING 
SYPHILIS 


(POX) 


Syphilis  is  a  deceptive  disease.  Usually  it  is  a  very  mild 
disease  in  its  early  course,  giving  the  person  afflicted  with 
it  little  or  no  distress.  Because  it  is  so  mild  its  victim  is 
likely  to  pay  little  attention  to  it  and  to  fail  to  go  to  the 
trouble  to  have  it  thoroughly  treated.  But  in  spite  of  its 
mild  beginning,  syphilis  is  one  of  the  very  serious  diseases 
because,  if  it  is  not  properly  treated,  it  may  later  attack 
vital  parts  of  the  body  and  cause  the  greatest  damage.  It 
may  produce  ugly  deformities ;  destroy  health  and  shorten 
life;  produce  blindness  and  at  times  cause  insanity.  These 
results  do  not  occur  so  often  that  you  should  become  panic- 
stricken  because  you  have  syphilis,  but  they  are  common 
enough  to  make  it  necessary  for  your  safety  that  you  make 
every  effort  to  get  rid  of  the  disease.  These  accidents  of 
syphilis  almost  never  occur  in  the  early  course  of  the  disease. 
When  they  happen,  it  is  usually  years  after  infection,  in  cases 
which  have  not  been  cured. 

The  earlier  in  its  course  syphilis  is  thoroughly  treated,  the 
better  are  the  results ;  it  is,  therefore,  of  the  utmost  impor- 
tance to  your  future  health  and  happiness  that  you  should 
have  your  disease  promptly  and  skilfully  treated.  If  you  do 
this,  there  is  little  danger  that  you  will  have  further  trouble 
from  it;  and  after  a  few  years  you  can  marry  without  dan- 
ger to  your  wife  or  to  your  future  children.  Your  medical 
officers  will  attend  to  treatment  of  your  condition,  but  it 
rests  on  you  to  do  your  part.    Unless  you  cooperate  and  live 


154  THE     VENEREAL     DISEASES 

up  to  instructions,  treatment  cannot  be  carried  out  with  the 
best  results. 

One  of  the  difficult  things  about  syphilis  is  that  to  cure  it 
often  requires  a  long  time — two  years  or  more.  In  two  or 
three  weeks  after  you  begin  treatment,  you  will  not  know 
from  any  symptom  that  you  have  syphilis,  and  you  will, 
therefore,  be  tempted  to  neglect  further  treatment.  This  is 
the  great  mistake  that  many  persons  with  syphilis  make. 
To  insure  future  safety,  treatment  must  be  continued  long 
after  all  evidence  of  the  disease  has  disappeared.  For  your 
own  good,  you  must  see  to  it  that  you  do  not  neglect  your 
treatment  after  the  first  few  months. 

Syphilis  is  a  contagious  disease,  but  spreads  only  by  contact 
with  the  virus  or  poison.  The  parts  of  the  body  that  most 
often  carry  the  virus  are  the  mouth  and  the  genital  organs 
(privates).  In  order  not  to  spread  the  disease  you  must  be 
careful  in  your  associations  with  others.  If  you  are  careful, 
you  are  not  dangerous  to  others. 

Obey  the  Following  Instructions: 

If  you  have  any  sore  on  your  genitals,  no  matter  how 
small,  or  if  you  think  you  have  syphilis,  report  to  your  medi- 
cal officer.  Do  not  under  any  conditions  rely  on  the  "blood 
medicines"  that  promise  to  eradicate  syphilis,  and  do  not  be 
caught  by  advertising  doctors — quacks — who  try  to  get  your 
money  by  promising  to  cure  you  quickly.  Do  not  let  drug- 
gists prescribe  for  you;  they  are  not  qualified  to  treat  syphilis. 

Do  not  hesitate  to  tell  your  doctor  or  dentist  of  your 
disease.  Later  in  life  if  you  get  sick  at  any  time,  you  should 
tell  your  doctors  that  you  have  had  syphilis,  since  this  fact 
may  furnish  a  clue  to  treatment  on  which  your  cure  depends. 

Live  temperately  and  sensibly.  Do  not  go  to  extreme  in 
anv  direction  in  vour  habits  of  life. 


Instructions  for  Those  Having  Syphilis  155 

Try  to  get  a  reasonable  amount  of  sleep — eight  hours  is 
the  amount  needed  by  the  average  person.  And  as  a  safe- 
guard to  others,   sleep  alone. 

You  should  not  smoke  nor  chew  tobacco. 

Absolutely  do  not  use  alcoholic  liquors.  All  experience 
shows  that  drinking — even  moderate  drinking  —  is  bad  for 
syphilis. 

Take  good  care  of  your  teeth.  Brush  them  two  or  three 
times  a  day.  If  they  are  not  in  good  condition,  have  them 
attended  to  by  a  dentist.  But  when  you  go  to  him,  tell  him 
that  you  have  syphilis. 

Do  not  have  sexual  intercourse  until  you  are  told  by  your 
physician  that  you  are  no  longer  contagious.  It  will  inter- 
fere with  the  cure  of  the  disease,  and  it  is  criminal,  for  it  is 
likely  to  give  the  disease  to  your  wife. 

You  must  not  marry  until  you  have  the  doctor's  consent, 
which  cannot  be  properly  given  until  at  least  two  years  have 
passed  after  cure  seems  complete.  If  you  do,  you  run  the  risk 
of  infecting  your  wife  and  your  children  with  syphilis. 

Early  in  the  course  of  syphilis,  while  it  is  contagious,  the 
greatest  danger  of  infecting  other  people  is  by  the  mouth. 
Because  of  this  danger,  do  not  kiss  anybody.  Particularly, 
do  not  endanger  children  by  kissing  them. 

Do  not  allow  anything  that  has  come  in  contact  with  your 
lips  or  has  been  in  your  mouth  to  be  left  around  so  that 
anybody  can  use  it  before  it  has  been  cleaned.  This  applies 
to  cups  and  glasses,  knives,  forks  and  spoons,  pipes,  cigars, 
tooth  picks  and  all  such  things.  It  is  better  to  use  your  own 
towels,  brushes,  comb,  razor,  soap,  etc.,  though  these  are  much 
less  likely  to  contamination  than  objects  that  go  in  your 
mouth. 

If  you  have  any  open  sores — you  will  not  have  any  after 
the  first  week  or  two,  if  you  are  treated — everything  that 
comes  in  contact  with  them  should  be  destroyed  or  disinfected. 


156  THE     VENEREAL     DISEASES 

To  live  up  to  these  instructions  will  only  require  a  little 
care  until  you  get  used  to  them;  after  that,  it  will  be  easy. 
If  you  do  live  up  to  them,  there  is  a  good  prospect  that 
syphilis  will  not  do  your  health  permanent  harm  nor  cause 
injury  to  others;  and  you  will  have  the  satisfaction  of  know- 
ing that,  after  your  misfortune,  you  have  acted  the  part  of 
an  honest  man  in  your  efforts  to  overcome  it. 


INSTRUCTIONS     FOR     THOSE     HAVING 
GONORRHEA 


Clap — a  Dose — Chordee    {Painful  Erection) — Swollen 
Testicle — Gleet 

Gonorrhea  causes  so  much  discomfort  that,  unlike  syphilis, 
it  is  not  apt  to  be  overlooked  or  neglected  in  its  early  course ; 
but  the  discomfort  of  gonorrhea  disappears  long  before  the 
disease  is  gone,  and  patients  are  therefore  apt  to  discontinue 
treatment  before  they  are  well.  In  such  cases,  the  disease 
persists  indefinitely  as  a  morning  drop  or  as  "gleet" ;  per- 
haps not  even  these  symptoms  may  be  present,  and  the  patient 
may  suffer  no  particular  discomfort  of  any  kind,  and  yet  be 
exposed  to  serious  accidents  to  health  and  be  a  source  of 
danger  to  any  woman  with  whom  he  has  intercourse. 

It  is  a  great  mistake  to  regard  gonorrhea  lightly.  Gonor- 
rhea may  occasionally  be  very  mild  in  its  symptoms,  but  if 
neglected  painful  early  complications  and,  later,  very  seri- 
ous ones  are  likely  to  occur.  Common  early  complications 
of  gonorrhea  are  chordee,  inflammation  of  the  prostate  and 
bladder,  and  swollen  testicle.  Common  later  complications 
are  gonorrheal  rheumatism,  gonorrheal  disease  of  the  heart, 
and  stricture.  These  later  complications  are  all  serious 
troubles.  In  addition  to  the  dangers  to  the  patient,  uncured 
gonorrhea — which  may  show  as  a  gleet  or  a  morning  drop 
or  not  at  all — is  as  contagious  as  an  acute  gonorrhea;  so 
that  for  the  protection  of  your  wife  you  must  get  well. 
Gonorrhea  is  the  commonest  cause  of  sterility  and  serious 
diseases   of  the  pelvic  organs   in  women. 

The  time  to  cure  gonorrhea  easily  is  early  in  its  course. 
The  sooner  proper  treatment  is  begun,  the  sooner  gonorrhea 
can  be  controlled  and  the  less  likely  are  complications.    After 


158  THE     VENEREAL     DISEASES 

gonorrhea  has  become  chronic,  its  cure  is  extremely  difficult. 
It  is,  therefore,  very  important  that  the  disease  should  be 
properly  treated  early  in  its  course  and  that  the  patient  should 
cooperate  with  his  physician  in  doing  those  things  which 
facilitate  the  cure.  Gonorrhea  can  be  completely  cured,  but 
in  its  treatment  the  patient  must  do  his  part. 

Obey  the  Following  Instructions: 

Persist  in  treatment  until  your  doctor  tells  you  you  are 
cured. 

Do  not  try  to  treat  yourself. 

Do  not  use  a  patent  medicine  or  some  "sure  shot"  that  may 
stop  the  discharges,  but  will  not  cure  you. 

Do  not  let  an  advertising  doctor — a  quack — get  your  money, 
and  do  not  let  a  drug  clerk  treat  you. 

If  you  have  had  gonorrhea  and  you  suspect  that  it  is  not 
cured,  report  to  your  medical  officer. 

During  the  acute  stages  keep  quiet,  and  take  little  exercise. 
As  long  as  you  have  any  discharge  avoid  violent  exercise, 
especially  dancing. 

In  order  to  avoid  chordee,  while  the  disease  is  acute,  sleep 
on  your  side,  urinate  just  before  going  to  bed,  and  drink 
no  water  after  supper. 

Never  "break"  a  chordee.  To  get  rid  of  it  wrap  the  penis 
in  cold  wet  cloths  or  pour  cold  water  on  it. 

Except  at  night,  drink  plenty  of  water — eight  or  ten  glasses 
a  day. 

Do  not  drink  any  alcoholic  liquors ;  they  always  make  the 
disease  worse  and  delay  its  cure.  Also  avoid  spicy  drinks, 
such  as  ginger  ale. 

Do  not  eat  irritating,  highly  seasoned,  spicy  foods,  such  as 
pepper,  horse  radish,  mustard,  pickles,  salt  and  smoked  meats 
or  fish. 


Instructions  for  Those  Having  Gonorrhea  159 

Always  wash  your  hands  after  handling  the  penis,  particu- 
larly in  order  to  protect  your  eyes.  Gonorrhea  of  the  eyes 
is  very  dangerous ;  it  will  produce  blindness  if  not  at  once 
treated,  and  the  infection  is  easily  carried  to  the  eyes  on  the 
fingers. 

Keep  your  penis  clean.  Do  not  plug  up  the  opening  with 
cotton  or  wear  a  dressing  that  prevents  the  escape  of  the  pus 
from  it.    Wash  the  penis  several  times  daily. 

Burn  old  dressings,  or  drop  them  into  a  disinfecting 
solution. 

Never  use  another  person's  syringe  or  let  others  use  yours. 
While  you  are  using  a  syringe  keep  it  clean  by  washing  it  in 
very  hot  water  and,  when  you  have  finished  with  its  use, 
destroy  it. 

Avoid  sexual  excitement.  Stay  away  from  women.  Do 
not  have  intercourse.  It  will  bring  your  disease  back  to  its 
acute  stage  and  it  is  almost  sure  to  infect  the  woman.  Sexual 
intercourse  while  you  have  gonorrhea  is  a  criminal  act. 

You  are  likely  to  obey  instructions  while  your  gonorrhea 
is  acute,  because  it  causes  so  much  pain.  Persist  in  this 
after  the  pain  is  gone;  by  so  doing  you  will  prevent  relapse, 
make  your  cure  much  easier  and  more  certain,  and  expose 
no  one  else  to  the  disease. 


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lo  .  M 

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RC201  Xjn3 

1919 
U.S.  Surgeon  general's  office 

The  venereal  aixanxaa. 


7 

12     c.  a  pnur^. 


1313 


